Document 2qMk4zmmra4bO2qkZ568bQ5ag
FILE NAME: Smoking (SMOK) DATE: 1954 Feb
DOC#: SMOK008
DOCUMENT DESCRIPTION: Journal Article - Occupational and Cigarette Smoking as Factors in Lung Cancer
' o f H e a lth 5em'nr|^;
t H C ic c e u t a w u u z t
AC* & VEATCH orm/tieg Enjin--rt
P U B L 11C H E A L T H
> 4 -- Electricity -- Indotiy
t r y rrd tiw s f C e m h iM iU , i n d ] tm 4 l e t t i .
Cecdi WonAly Publication of the American Public Health Association, Inc.
tdwty, Kent City 2, M*
ABOUND IODINE TESTS MllBf iftttf'l 1 HMfiUU,
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M m e 44
ito
February, 1954
Number 2.
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IXSON YENAILE, P. L mid %*4 Ckvmtcal Ea^ia*
!"S. 'Program Planning T o o l
AfwpWti FWUli,
A Program Director's Guide
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)NAL EXAMINATION SEI
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I are that inform ation e ffectirely, It tide paper't th em e.
l' rop'Tly undorsl'Mxl and used. thre rcpurt can he an efTeclive *ervant. lending a slrmi" limili in dumping program
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The benefit * of brewer' jt t t i
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union and animal nutrition a l f record. It is generally rtrouM j
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in ita production.
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S"*`T **mry
Occupations and C ig arette Sm oking as Factors in Lung Cancer
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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 ffe rs ad d i tional evidence ten d in g to con n ect Leary cigarette sm o k in g will can
ti* . la addition, it U sti several trapalloris that teem to hare nome etiological rela tion sh ip to the 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.
Dr. llrrslow is chieh Bureau of Chronic Disease*. California Slate Department of Pub
tV* ran hardly presume that physicians Litr applied diagnostic improvements m much more completely to men than
lic lleallli, Berkeley, C alif.; and Mr. Hoaglin ami Mrs. Uasmnssen are also associated with this department. Dr. Abratns, who was
formerly chief. Bureau of Adult Health,
1 omen. Likewise, the increasing profa tl ion of lung cancer found as a cause aj death among autopsies supports the
California Stale Department of Public Health, is now medical director, Health and Welfare Kund, Chicago Office, Theater and Amusement Building Janitors1 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 (C S 9047) lrom the Na tional Cancer Institute, P H S . and was prewilled In-fore the Industrial Hygiene Section
irr the best explanation for the oth(ethKeigAhmly-efriricsal nAnPnuubalilc MHeeeatlitnhg AinssoNceiwatioYnorakt,
piwnomcnon. Previously published N. Y ., November 10. 193.1.
171
\
F E IJ.. 1951 A M E R IC A N JO U R N A L O F
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 ?tiw fi*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
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km
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L U N C C A N C E R V O L . 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
if
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 s m 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
Table 1-- A ge D istrib u tio n o f L u n g C an ce r Patients and Co n trols
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 E R IC A N JO U R N A L O F P U B L IC H E A L T H
T alile 2-- Sex and Race Distribution 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
White
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
White
3
IS
18
18
Negro
1
3
4
4
2
Other
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 I pipe, 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,
fe l
did not t
ITt- - Om rnmmon'
of expo
T ab le 3-- T obn ceo U sage D u n n e 20 Year P rio r to Study Reported by
Lung Canrer Patients and Controls
TiU S--Axe
Cases
Co Coatrdi |
Manner of Using
Adeno
Other Types
Tobacco
carcinoma
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 tiis re 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 C A N C E R V O L 44 17S
Tali] Am ount o f C igarette Sm okin g D u rin g 20 Y f a n P rior to Staiiv Rt'|HK1ril by l.n n g C a n rcr Patient nml 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
t im 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 CignreM e S m o k in g , S m o k in g H ab it, and " C ig arette Cough" Reported by Lung Cancer Patients and Controls
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 Cigarette 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 A M E R IC A N JO U R N A L O F P U B L IC H E A L T H
T a b ic 6-- Estim ated Prevalence R a le* * o f L u n g Cancer per 100,000 Mala o f Selected A b nml Various Cigarette Sm oking Ilabtl
af Ion ________ _ &t liV
Number
Lung Cancer
Control
Estimated Prevalenre Rates Quantity Smoked Daily t
All Quan Heavy ** tities
None
Relatin fejeTtmiia? T a an
Prevtlenctt & fee* ly
rt
. ^V
Booking
la the l
Heavy t
Theee
Patients aged 50-59 years
I . Doll ami Hill
276
275
94
42
2. Wynder and Cralum 258
210
117
47
5. Sadowsky, Gilliam,
I s |W e i la categ
7
13
aotoking,
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
0
, #
2. W ynJer and Cruliam 187
lot)
138
70
5
29
3. Sadowsky, Gilliam ,
and Cornfield
76
71
44
71
5
9
4. Present
168
169
433
78
17
25
%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 a ily , e t t t p t lo r p f t m t M u J y , i< a l l fo rm a mt m o k i a | e t p ram 4 i t c i | m U a , w kk
e i f a ra c a a r m r i t a i b a ir i ^ a i u l e a i i i* e if a t v t t e e aa l a i i a v t i 1. D o l l i t i H ilV--! oc, ! ta b a c c a a w e a k S 4
a d a y ; 2. W y a d a r ad C ra k a m -- 1 c le a r s r 5 e ifa re tte a , 1 p ip e fu l s s 2% tifa r c i!* * ; aa d 3. S adow aky,
C o m c M -- 1 c if a r -- 14 e ifa re tte a , I oc. p ip a ta b a c c a =s 24 e ifa re tte a . 4. F a r preaea t a ta d y , q u a n tity --
?5
a
ttf
tf
'n
J Way K V* af cigtrv OMOMkrC, (Sue
*ka * y .)
f o etW. UtUiic for tfata
torrUigatio ta make c ghbl aat aiuwer to
does ci
ta rlu d e a a n ly c ifa ra ttc amok*.
I Relatta peccale*# la tha ratio: lleavp^raia aataof beaey makera/r** ama* seeamakat; all Mddm amuiif maker/rat* ameof naaamokaia.
lla a e y m e i i | ta d e fin e d aa th e f a lla t e m i a a m k e r o f c if a r a t t a a oe r a i* a ) tt o f e if c r e t t c p a r day y t
a a d I liJ I -- 50 o r m a r e ; 2. W y iid e r a a d C t a h c m -- 3S o r m a r e ; 3. S a d o w a k y , G illia m , a* d C o r a b e id -- 41 m H |
4. p re 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
ralirrm cn Animal amJ Farm hantir. Cenerai wix..
rlwwherr i Painters, esci Jb k k and << Caa.iruclion |j*eomoli*e fi, Attendant, li H i Mechanic* mi
SUMI || ll ruth.
4 b a a *M m * *u m* * t> \
* mm laa*4a4 Mr4u
P . C i V.
<*.**
S3
L U N G C A N C E R V O L 44 177
BUfihood of lung cancer? Further, errase the likelihood of lung cancer?
*$1 m
*44 ij that likelihood in absolute t n a ! To answer these questions ; Wautely would require that records of
Application of Cornfield's formula M> ls to the data from four studies, including the present one (Table 6 ) , indicates that
*3
dptette smoking for large numbers of for men aged 50-59 the prevalence of
poena in the lung cancer age be lung cancer is from four to 11 times as
allied. These persons would then great among smokers as among non-
! placed in categories with respect to smokers, and from seven to 27 times as
fjprrtte smoking, e.g., nonstnokers, great among heavy smokers as among
i m in t it smokers, and heavy smokers.
fWUy they would be olrserved for a Aricnt length of time to determine the to of lung cancer among the various
nonsmokers. Similar ratios were found for the 60-09 age group. This formula involves the assumption that in so far as smoking history is concerned, the pa
wyorifs of cigarette smokers and the tients are a representative sample of all
wankers. (Such studies are now lung cancer cases and the controls are
a W way.)
a representative sample of ail other per
However, statistical devices have been sons in the general population.
Jtmloped for data such as those in the
Crvk**; ad
***ent investigation which, if one is oar to make certain assumptions,
Findings on Occupaiions
J W an answer to the question, how As noted earlier, the records for lung
Marts times does cigarette smoking in* cancer patient and controls showed all
tamikUa m
Table 7-- Tw enty l'r r cent S a m p le from Com plete List o f Occupational Croup 1 in W hich There W ere at Least 5 Cases or 5 Controls Em ployed for 5 Years or More
s parallel
controlled
e correl*
; and lun$
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 farmers
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 maintenance
3
6
j I Brick and stonemasons and tile setters
S
1
| 132 Construction occupaiions, not elsewhere classified
45
25
j 1 C Locomotive firemen
3
6
1 - 60 Attendants, filling stations and parking lots
10
9
, 13 Mechanics and repairmen, 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 t a 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 J O U C N A l . *M H i U C I I K U . T
T iilflr U--
<n>np* ' i n W h irl* ih r E m p ir n r * n f i M 'ir
E m p lo ym en t A m m is ( .im* W :n nt le j n l T*ir* a*
, _
( m il u A m o n s (io u iro U
ample, one occ ' 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.umliermen, raftsmen, ami wood rhopper473 Machine 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 Welders and flame rullrr520 Occupations in production id petroleum 523 Construction machinery o|x-ralors, not
elsewhere class! fieri 524 Brick and stonemasons and tile setters
10
1 n
f ~;tory of controls.
.>
. including steam
i 3 r . and boilermake
.>
1
re to asbestos-
538 Brakemen, railroad
10
5
570 Firemen, other than proce- firemen
11
2
573 Cranemen, derriekmon, hoist men. and -hmclmen
15
(,
575 Drillers, extraction of minerals and construction
2
lunes among tl time among the
; Table 9 prese lions grouped
* O c r v p t t io a t claai*<) r t o r d in r to tli* D ic t io n a r y o f O c r u p .stio aa l T.l* Crv-1 c d . ) .
significant gxpo
t a h in f t o n , D . C . : U . S . F.m ploynirnt S * r * ic c . 1*M9. Inclut!* only occu paio nt s tu t !C S co*a ii h S year or m ore ! rm 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 a b 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
* Ore*patio*
4#tail**4 fu*ii*t
l.U N r . <c .:\.\Nn (u,r .:ikt vV (<u ,, -iiii t:n
Itoffc, one occupational group, number ix-cui'otions may be involved in lung
X * Iplombcrs, gas filters, and steam cancer.
Stoni showed 16 cases and 10 controls In recent data of Doll 10 the only
a five-year employment history, occupation with an important cxccs in
taaaieation of these 26 individual the cancer group was that directly con
j w revealed that substantially all cerned with the production of gas. l.iltle
fc focace between case and control or no support was found indicating that
fcfce was due to the steam fitters who other occupations suffer sjxxial risks.
a heavy exposure to asbestos. It However, Doll's study was based upon
he noted that other types of work experience in England where the em
iag asbestos occurred more ire- ployment pattern differs from that in
in the employment history of the United Slates, especially California.
dun among the employment his- Also, Doll used an occupation code of
controls. Thus, a new category^ only 76 categories which may have l>cen
steam fitters, aslieslos workers, too coarse to reveal the. di(Terences
d boilermakers-- all involving expo- found in the present investigation where
la asbestos--was found to occur 10 a code of 367 categories was used and
among the cases and only one analysis carried to subgroupings of
t ong the controls.
-- these.
9 presents the data for occupa- It may be noted that 77 persons with
pouped according to possibly lung cancer had an exposure of more
^ fra n t exposures. Although num- than five years to suspect occupations
V la each of the categories are small, (unduplicatrd count in seven occupa
iti trences between cases and con- tion groups) according to the data in
Ubifpear to implicate the occupations Table 9. This number represents a not
to any one W>
<s impressive tb *
le smoking.
J
ith which the leaf.!
ursued certain *
itially greater ihtt
which control
}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"
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
hese same occmw
iV
lor which the l m ' ' was at least \mim
Table 9-- Cases nnd C o n trols E m p lo yed fo r ut Least 5 ) f a r s in Selected Occupation Croups *
controls, using tW-. ition category 1*
Persons Employed in Occupt ion at Lea*t
>ie 8. Such a U W
Occupation
5 Years
'ws the occupati |
C.ontfols
<> an arbitrary cafa-|,
*ed to reflect
li l tt'eldcrs and sheet metal workers doing welding
u .
2
:J~ L Stesm fitters, boilermakers. and asbestos workers
1ft
1
posures that ral$J(v
l Electric bridge crane operators-- metal industry
5
1
jig cancer. Further,
i Occupations in the extraction of lead, zinc,
included the J m'A of records of
controls and lions according to*!#,
tnd copper ore l Marine engineers, firemen, oiler*, and wiper :"h t Construction and maintenance painters X Cooks, commercial (excluding cannery cook*)
9
3
12
h
22
12
3
21
\posures. For "
'O r tiftti jrrmp
ti
rru rd in f l* rnnm uii orrpiit*i| ` ipnsuf* j h n
nM i i i n w i l i M ' o f
m
i b h *dSrI., e s
hi
L
' MfiV-J - ; 1; ! f!rl 3: 7 ` id :y ] ; *\Y yd IS t
t.!l>
V
I
180 F E IL , 1954 A M E R IC A N JO U K N \ L OK IMJUL1C H E A L T H
T a b ic 10-- Exruui'Ir o f A<lju**imcnl fo r Sm o k in e A pplied Io F e h le r ail Sheet M ctni W o rkcm D o in p W eld in g
Packages oi CigarcHc Smnknl |-cr Day
how L*
group lung a smokin
None
U. --
1 -
2 or more
Noi re*
Total
Conclu
A ll c u e s and controls, male * 1. Cases 2. Controls 3. Total 4. Proportion of cases among total cases and controls
Welders 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 nl i cM B i f w fld fti = ---- 1 s 0.S 6 J
H
14
Ob*nr*4 p ro p o rtio n ( r i M i i o w ( r U m s -- = M ? S
1
14
N ia iy* 6 * p o r e r o l co o d * o Jiotif { lo r tb p ro p o rtio n -- =
I level.
16
(0 .6 1 7 , 0.<*6D -- 'ftt'O ie a lly
*< cn6raai I IS fm
Fem ale e tria d e tf ir o n to ta l iro u p * oro * *ly m ole or {eluded io roup to w h ich ir t w o ap pi'ird.
t O b t a in e d b y a p p ly in g t k o p r o p o r t io n o( { w * t o | t o ta l r*e a n d c n n t r n la in e a c h m o tin g c n ir y o r y ta U
nnaabor of w elder in that ao io k to f e*te*efy (U ne N o. 4 X Una N o. 7 ].
! H a id A. S u t i a t 'c a i T a b le a n d F o r m u la i. N e w Y o r k : J o h n W ile y . 19*3.
N o te ; T b ia teat aiao waa a p p lie d to a il oth er o rtn p a tio n group* a/towo in T a M a 9.
T h e i r o u p " te a ts fitter
b o f ia r m a k a n . ta b e a to w o r k e r " w aa o n th a b o r d e r lin e o f a t a t iftie a ) a if a if t r a o e r at th e 95 p e r r e n t le v e l. N o n a af tfci
n lb e r g ro u p m e t th e 9% p e r r e n t le v e l of f ta ti t ie a l ic m h e a n e e .
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 .A N C E K 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 La n g in U r la li 1 T e b cr . B r a . J . C a a tt r
5:1 i I .
The data in this study constitute still
2. S rfcrrk. f u Baker. U A .. B a ila r . C . D o lc o ff. S . T o b a r re* S m n k t f t f a t aa f.t
TV. ) *1 F V
another link in the chain of evidence connecting lung cancer with cigarette
l a r i D ia r a a r . C a n r e r R ****b 10 49-5A. 1950. 3 . W y n d r r , F.. L . , a m i G r a b a n , E - A . T r b a r r n Smk-
in f aa I'o ew M e L liu ln f it F a rtn r m
Mnvking, evidence which the New Eng land Journal of Medicine notes to be
C a r r m m ta . A S fu d y o i 6 4 l I'm **! Cava.
1 .329-J16. 1950.
4. D o it. R .. anH H ill, A . R . A Stud*
tb r
J.A .M .A . A rtm lrjy
" *n strong as to be considered proof within the everyday meaning of the word." 14 It is time for those concerned with health education and with the ethics of advertising, at least in health
o( C arcino m a o i th* L v n f . B n t. M . J. r i l ' I - U M .
1932.
3. L rv tn . X , L., (fo M a irtfi, H ., and C *rh rdt, T- R.
C a ne ar and T n b a e ro S m o h in * . A P te lim iD e ry Re*
pert. J .A .M .A . 143:336-331, t W .
6. K e e p e r, T . C . (V a n p a tm n a l Tom or and A llie d
O ioraaea. S y t in c b t lU , U K ; TH m aa. 19\2.
7 . Reatnak), O ., Sp. E -, and S < h m rl. C .
O i
and medical journals, to lake note. Further investigation should seek the
D e r f k r o k h f a d o r E r ib e t e J e t e i* S c k o r r b r r f La S a cb a e n <*4S h n e b e rc e r L u n f e n b r r b a " ) . Z ta e h r. (. K re b a fo ra rh 2 3 - J b O - 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 a rk!* . V . , d G re f rio a , F . C ancar a i ib
R eaptm lory S yrtcm in tbe U n ite d State. P u b .
H e a lth R ep. 41:1116-1127. 1949.
9. GW ywe, S. R . P n n m o co n io il; llia tn ln fte a l Survey
o l N e e ro p e y M a t e r ia l 1 1705 Caaea. l-e n re t 1 :810,
1931.
J. 10. D a ll, R . O r o n e b ia l C a r c in o m a : la c t d e n e a a n d A r t i,
e lo fy . Part t and P a ri IK B rtt. M .
531*137,
$ > 3 9 0 . 1953.
11. C a m b r ld . 1. A M e th o d o l E rtiro a tia g C o m p a ra tiv e
R a te a rt> C lin ic a l D a ta . A p p lic a ti * ta C a a e c r a f
la the development of lung cancer. These occupations should now be in
the 1-unt, Breast, and C e ra ia . J- N at. C ancer )l:) 2 f* 1 2 7 S . 193!. 12. Sadnw aky. D ., C illia m , A ., and C o rn field , J.
Inat. Tht
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 ra o e ia ti f le iv e c fra n k in g and Car* r in am a a i the L u n g . Ib id . 1 3 :1237-125fi. 1933. 13. V y n d e r . * L .. and G ra h a m . E . A . E lio )o (ie F acla ra t* B frm ch ioce ntc C a rcin o m a w ith S p e cia l Refute*# ta ln d e ia ! E a pnvuree; R e p o rt o i 8*7 F ro v e d Caae. A rc h , lad uet. ]( f. A ( V t u f . M e d . 41721, 1931. 14. E d ito ria l. C a n re r of |he L n n f. N e E n fla n d J. M e d . 249:463-466, 1933.
Journal 25 Y e a r s A g o
A d dend um 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
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