Document 6BNnVoRjMN7mY4NkjkYagb251

xos ____ Asbestos Exposure, Smoking, and Neoplasia Irving J. Selikof], AID: . Cuyler Hammond, Se:D; and Jacob Clung, AID. Asbestos insulation workers,, as a group,,have_ ajhigh risKjjf,,dxing_q(,,broncftogenic_carcinoma_(about_seven_qr eight times.expected). We have observed 370 such work due to chance, the number of such deaths lici:.-.' J small. During the latter part of the study, we ob; i tamed information on the smoking habits of mo.". | men from Jan 1, 1963 to April 30, 1967. Our findings indicate that asbestos exposure _alone.isjn.ot.the entire of the survivors, but we could not obtain reliable;:! information on the smoking habits of those who* } .explanation. Of 37 noncigarette smokers, none .died_of bronchogenic carcinoma. Of 283 workmen with a history had d`ied at an earlier date. Therefore, we couuldld.:| not at that time investigate death rates in rch--; 'd..C?gular_cigarette.smoking, _24. died of. bronchogeniA/-- tion to smoking habits and exposure to ashesua, tarcinpma. although only three were expected, to die. of/\ dust which were considered both .separately and-.- ,his_d.lsease. Calculations' suggest that asbestos workers* jointly, ' who smoke, have--about 92 "times'the" risk"of "dvih'g~of bronchogenic carcinoma as men who neither work with asbestos nor smoke cigarettes. We conclude that"asbestos Thgrejs abundant evidence that cigarette sraok-t ing. leads to a high rate of death from lung cancer .' m_t_he_absence of occupational exposure to asbestos- exposure should be minimized, that asbestos workers who dust.' * Qur.findings.qyJ.Uned above suggested.(buti. do not smoke should never start, and that those now ' smoking should stop immediately. ,, did'not prove) jthai-ax'posure. to.asbestos dust mays*. lead to a high rate of death from lung, cancer in-A the,abs&nce of cigarette smoking. If tba-Jaiier bei-': (. at ii* CX iilin n 1964, we reported on deaths occurring between so, then the combined ellect of both types oba-s I Jan 1,* 1943, and Dec 31, 1962, among 632 posure might or might not be etjual to or greater.-:: members of the- International Association -of Heat than the sum of the two effects. Qn the other hand,,;: and Frost Insulators and Asbestos Wor-kers.* All it was .possible that exposure to asbestos dust, in-v/ -of-thesa. men had-bean occopa tionally-cx posed to creases-the risk of lung cancer among cigarette*- asbestos dust for many years. Their death rate smokers but does not lead to lung cancer araoasy- from lung cancer was found to be 6.8 times as high iiqnsmqlccrs. ` as that reported for the general white male popu The present study was undo taken primarily* lation of the United States during the same years, to investigate these possibilities. In addition, we with age taken into consideration. Three of the wished to obtain more information on the occur-*: men died of diffuse pleural mesothelioma and one rence of mesothelioma and gastrointestinal cancer,: died of a neoplasm histologically suggestive of peri among asbestos workers. -Iv or a* at. liv U' toneal mesothelioma. This was of interest since > mesothelioma is a very rare tlisea.se in the general population but is reported to he associated with exposure to asbestos dust.' In addition, their death rate from cancer.of the stomach, colon, and rectum .was higher than expected; but this may have been From the Department of Community Medicine. Mount Sinni hool of Medicine (Do S:likoflF ami Clnirg), and the Depart* ment of -Epultmiolouy and Statistics, American Canter Society < Or.'Hammond), New York. * Mend before a joint inrelinu of the Section on !)israir< of the 'Chest with the Section on Preventive Medicine and the American Collette of Che*l I'hysirnutH at the lltith imuuil ronventioit of the American Medical Avtocmitnn, Atlantic City, N.f, done lit, 111G7. Kcprint rcquej*l to Mount Stnai School of Mwitrtn*. 100th Street mrt Fifth Avrnti# Vorlr |0ffcN* 'hr St*tit|-4Tt Material 7" ,4 From record-. of New York Lora, i'l and Newatit,'..- NJ, Local 32 of the International Association Heat and Frost Insulators and Asbestos Workers.?* a list was made of every man who was a member?? of either one of these locals-on D'-c 31. 1942, oif; who joined between that date and Dec 31, I96'2.r"- No one was omitted regardless of his subac-iueal-- work history. Personnel data from union records indicated that/'; of the 632 on the union rolls on .Jan 1, 1943. 339j l-Jlj of the men had first hia-n orcupa! innally oxt-oat-.d..y i to asbestos dii-f pi in- : . to:'-' .-l ,n > i-' 0o290 448059 4>a . -a ' '5 ...hV* insf*c.l -(/}! u6 >-' *. 1 ... .<2 ASBESTOS EXPOSUnE-SELIKOFF CT At. 107 29,1 men had first been ex posed between the be Table l.-Sub|ects Ctassiti<] by Age as of Jan 1. J963. and by Years ?Yo.n First Gccupatir- m Exposure to Asbestos Oust up to Jan 1.1963 '* ginning of 1923 and. the end of 1942. AH of these men were successfully traced through Dec- 31, 1962, and 262 of them uere found to have died up to that time. Of the 262 deaths, seven oc curred prior to the 20 th anniversary of the man's first exposure to asbestos Am, Tr 3549 40-44 4$49 50S* 55 59 60-64 65-69 70-74 75-79 80-84 Total Total No. of Subjtctt 2 13 32 109 60 42 49 38 21 4 370 20-24 2 12 . . 1.7. ... ... 31 No. at rn Sine, firu Eipoiur. la Alta,,tj. 25-29 30-34 35-39 4fr44 l 2 i 1 13 80 16 ... . 78 34 r. a1 ..l. ... ...... 3 11 ... . 1 . 10 ...3.. 19 18 12 1 b 18 6 5 1 7 113 86 c5 39 . 04- 2 17 IS 2 36 No. of Oejlht, 2 M. 1 2 13 u 16 t7 a 3 94 dust and 255 occurred after the 20th anniver sary. Thus, of the 632 men. 370 were still living on Jan 1, 1963. These 370 men were the subjects of the pres ent investigation. Table 1 shows their age distribu tion as of Jan 1, 1963, and the lapsed time from first exposure up to that date. All 'of them have been traced, and 94 of Table 2.--Subjects Classified by Age and by Smoking Habits on or about Jan 1. 1963 A (, Yr 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70*74 75-79 80-84 Total Total No. 2 13 32 109 60 42 49 38 21 4 370 Neyar $moh6 Aogulorly i 2 2 12 6 7 6 7 3 2 -- 41 he*. Cigar Only .. .. 1 6 5 4 a 7 7 l -- 39 Current Cixaratta Smokcra* 6- r* cigarcR* 1-9 10-19 20.39 40+ Smokcra* a O.y a Day a Day a Oay i ... -. - .. . . . 2 ... . S 4 s ... .. 12 * 12 26 3 S 33 24 16 ... 3 20 10 IS i ... 11 4 17 . ,, _ 4 9 s 12 i ` 4 4 3 6. i31 Iwin. ... -- ... ... --# -_-_i - 101 s 17 97 63 them were found to have Inctuflti cigaratto smokers who also smoMO pipss or eigar*. died during the four-year and four-month interval from Jan 1, 1963, to April 101 were excigarette smokers, five currently smoked 30, 1967. one to nine cigarettes a day, 17 smoked 10 to 19 Beginning in October 1962, we made arrange cigarettes a day, 97 sgeked 20 to -39 cigarettes a ments- to examine these men periodically, once day, and 63 smoked-40. or more- cigarettes a day. every six to twelve months; the interval depended The smoking habits of Ilia 370 subjects were upon age and physical condition. The examinations compared with the smoking habits o> a large num include chest x-ray films as well as physical ex ber of men selected from the general population.' amination and cover past and present smoking There were proportionally more cigarette smokers habits, occupational history, medical history, and among _lhe 370 subjects than were found in the current physical complaints. Altogether, we have general population sample; age was taken into examined 338 (91.4 ) of the men at least once consideration. ...... and have repeatedly examined most of those who Causes of Death.--A copy of the death certificate are still living. - was obtained for each of the 94 deaths, fn addi Information on smoking habits was obtained by tion, vve examined hospital records, postmortem personal interview with the 33S men who were ex findings (41 cases), as well as the surgical and amined. Of the 32 men who were not examined, pathologic reports when surgery was performed (39 six told us their smoking habits by telephone and cases). We also reexamined histologic specimens. five gave us the information by mail. The local It was found that the death certificate was inac union secretaries (who personally knew these men curate in 14 instances. However, this did not alter *'H) ascertained the smoking habits of 18 men, the picture as much as mighL have been expected aad family members supplied thu information on since there were several compensating errors. For toe remaining three men. This accounts for all of example, in one instance the death certificate in to* 370 men. Table 2 shows their smoking habits dicated bronchogenic carcinoma ns the cause of n or about Jan 1, 1963, the men being classified death while a review of the histologic specimen their ages on that date, even though some showed that death was due to pleural mesothe changed their smoking habits between 1963 and lioma; but in another instance exactly the reverse 7. was found. Likewise, review in one instance re QL the 370 men. 48 never smoked regularly, 39 sulted in changing the reported cause of death jrcnked Q1. jini-t smoked pipes or cigars but never from bronchogenic carcinoma to cancer of the ~92k?!Lj:ifiMetc3jregularjy, jnicT^SJ ha'd"smbkcd stomach with metastasis to the lungs while review jjgarettes regularly. Some orthose'with'hrsfbry~of in another instance resulted in exactly the oposite c'Mrette smoking also smoked pipes or rig,ire. Of change. TllcJM. deaths were ascribe'.! *'* d foJh'w- to* 28.1 with a history of regular ri;:nn>Mo -anxWnir ' "" 06291 448060 loa ASBESTOS EXPOSURE--SELIKOFF ET AL Table 3.--Observed and Expected Number of Deaths Among 370 Asbestos Workers Ourtng the 52-Month Period white males of various a gets during titer yL-:ir )<;<*,{ as reported by the National Center for Health Sl- Cause el Oeallt Observ Oeatr.. C'Occtrd Chains* Total, cancer (all vies) 49 9.6 Cancer of lung, pleura. bronchus, and t'acnea Bronchogenic carcinoma Pleural mesothelioma Peritoneal mesothelioma 27 2.3 in Table 3. 24 f 1t Expected us Observed Deaths.-As shown ;:i 7 t Table 3, there were 94 observed deaths (ie, 0| o' Cancer at tlomaen Cancer of colon a'nd rectum Cancer of all other sites combined Asbestosis 3 0.6 the 370 asbestos workers died) as compared \W;n s 7 12 4S 47.3 deaths expected on the basis of the uge-spi'cnH IS . . . death rates of all white males in the United Stattr Heart and circulatory diseasa including stroke All other causes of death 22 28.S in 1964. Thus, there were 94 minus 47.5 a .|g j. 8 10.4 excess deaths. The excess deaths were due to hror..*' Total, all causes 94 4 7.5 chogenic carcinoma, mcsothelio.ma 'of the pleura- "Based uoon US mortality data disregarding smoking habits. fUmted States data not available, but figure should be only slightly less than 2.3. (United States data not available* but these ere rare causes of death in general population. mesothelioma, three: peritoneal mesothelioma,jev-^ en;.cancer.of .ihe~colon, four;.jcancerjjf.the.rectum. one;_ cancer of the stomach, three; cancer of the and peritoneum, asbestosis, and cancer of _thu- stomach, colon, and rectum. ................. ~. <,,:? Cancer of Lung, Pleura, and Trachea.--In pm>-T lished mortality' data for the United States snow., ing deaths each year from various causes by age,-; sex, and race, the following diseases are combineti:.- cancer of the lung (including sarcoma of (he lung)-"- pancreasrEivb; cancer ofbuccal cavity'andjharynx, cancer of the bronchus, cancer of the pleura, aw! two; caricer~o_bladder, one; cancer of undeter-1 cancer of the trachea. For._this..group of diseases,: mine.d primary"site.Two; asbestosis,. 15; cor pul- th__.e.re _.w__e_re 27 o_b__s_e_rv_e__d d_e__a_th__s a__n_d o. nly 2.3 ex-`. monaie. onefcofna^i'eart"disease,_17j..c6ngesfive / pec ted' deaths, a'ratio of nearly 12'to'll heart.failure, _one; .cerebral yascularjesion, twoit is well known chat, for the United States aortic aneurysm, one; cirrhosis of the liver, three; | 'a whole, all except a vury few of the deaths rt- bronchopneumonia, one; encephalopathy, one; ported in the combined category are due to brrm-" acute pancreatitis, one;'"Wegenerj granulomatosis, one; and~accidentarfaIl,~*one. " "ExpectetTDeaths.--For* purposes of comparison, chogenic carcinoma. Thus, it may be assumed that there were close to 2.3 expected deaths from this cause a.rcompared with 24 observed deaths, a ratio we wished to ascertain how many of the 370 sub of over 10 to 1. ` jects would have died during the 52-month period Mesothelioma.-en of ther-94 observed, deaths (Jan 1,1963, to April 30,1967) if their age-specific were due _towwe*dthe!iomar -three, .were .due. Jo ; death rates had been exactly the same as for the pleural mesothelioma, and seven were due to peri general white male population of the United States. toneal mesotheliomas. This is such a rare disease For this purpose, we made use of the United States that if the 370 subjects had been selected as a 1964 life table for white mates; this provided the random sample from the general population, one most stable basis for comparison. It should he wp.uld not have expected any of them to die of - noted that for white males total death rates and mesothelioma within a period of 52 months. '. ' death rates from respiratory cancer were slightly All. three of the men who died of pleural meso higher in the industrial states of New York and thelioma had a history of regular cigarette smoking. - New Jersey than .in the United States ns a whole.1' '' Of the seven who. died of peritoneal mesothelioma, On the other hand, respiratory cancer death rates in one never smoked regularly, one smoked only pipes white men oped 20 to 64 are reported to he a trifle and.cigars, and five had u history of regular ciga lower than average among laborers, not elsewhere rette smoking. classified employed in construction work.* Cancer'of Stomach, Colon, and Rectum.--In our' From the life table we determined for each of the earlier study of asbestos workers,' there were more- 370 men the probability of bis dying within a pe deaths than expected from cancer of the stomaca. riod of 52 months, considering his age on Jan 1, colon, and rectum (9.4 expected, 29 observed). As 1963, and assuming that the life table probability compared with a total of 1.3 expected deaths from applied to him. Summing these probabilities for the these causes, there were cighl observed deaths in , 370 men yielded an estimate of the "expected" this study, due to cancer of the following sites:- number of deaths under the null hypothesis that stomach, three; colon, four; and rectum, one. Al the age-specific death rates of these asbestos work though this bears out our earlier findings, the num ers are the same as for United States white males ber of deaths from those causes was so small tbao in general. The computation indicated that 47.5 \wc still refrain from drawing any conclusion at- deaths would have been expected. \V&. 'Vl/this time. ~Next, we wished" t6"estimate the expected num- Asbestosis.--Asbestosis accounted for 15 of the her of deaths from each of several causes. For this, 94,.dcaths. Wlule" it is not surprising that deaths- we made use of the percentage distribution of from tliis*disease occur among men exposed to- deaths by cause of death among United States .ishestoa dust, atU-nfion must he ralle-i t-> the n't 448061 06292 ASBESTOS EXPOSUHE-SEUKOFF HT AL 100 that these subjects were primarily insulation work* ers. While all of them were occupationally ex posed to asbestos dust, their degree of exposure ivas light as compared with the degree of ex posure of asbestos miners, processors, and weavers in earlier times. Bronchogenic Carci noma.--Bronchogenic car cinoma accounteti~fof~24 deaths while only about VI were expected on'the Num0er af LunS C*nccr deaths Expected to-Occur Ourinv a Period of 52 Months per 10.000 Men Living at tt.e Start ut Period; by Age and by Smokin;; Habits* Am. Yr W.n 1. 19831 33-39 40-44 45-49 50*58 55*59 60*68 65-69 70*78 75.79 80*88 Nev#r Smokvd R.KuI.rly 0 2 2 7 * 16 U 12 28 25 Pip. Ciit.ir Only ...r 12 15 31 32 52 S3 3? Smakertl 5 74 10 22 53 71 97 100 100 188 1-9 4 04/ .. ... ... 23 80 .. . 103 ... Current Cl, 10. to 9 04/ r , 44 91 157 206 185 zo 39 9 1)4/ 15 39 69 117 190 30S ?8* 341 404. 4 O4/ 15 46 90 135 25* 350* 4S0* 329 *89t4 upon data from a prasptcova study with adiustmint tor US mortality expense* | Ellipses indicate rates omitted for categories *ith no $uO|ct m this study. See To We 2* {includes Cigarette smokers who also smoked pipe or cigar. Mon vmM a history of onfy eisarett* smoking have mgfter lung cancer rates than shown here, 7 cigerene {Rates obtained by smoothing the dau. hasis' of generaf"UnitecLStates mortality, data for divided into many five-year age groups, some of the whitejrnajes. However, as previously mentioned, subgroups contained only a small number of men. evidence at hand suggests that there were propor In consequence, the lung cancer death rate was tionally somewhat more cigarette smokers among statistically unstable in some of the very small sub the 370 subjects than among white males in the groups. In three instances where the observed`rate United States as a whole, age being taken into in a small subgroup appeared to he badly out of consideration. This might have partially accounted line, we arbitrarily made an adjustment to bring ft for the high bronchogenic carcinoma death rate of more into line-with adjacent figures in the table. the subjects. For this and other reasons we made These adjusted figures which are indicated with estimates of the expected number of bronchogenic symbols m Table 4 carry very little weight in the carcinoma deaths, the smoking habits of the men final calculation. All-of the rates were then ad being taken into consideration. This was done as justed as follows: lows: _ Lung cancer death rates in the United Slates Data are available on lung cancer deaths in re have risen steadily year by year and were higher lation to the smoking habits of 440,000 men en in 1964 than during the period 1960 to 1964 as a rolled by American Cancer Society volunteers in whole. Furthermore, in the study described above, . a prospective epidemiological* studybetween Oc we avoided enrolling setkRfsly ill people and, as of tober 1959 and March 1960 and traced through the cut-off date for printing tfit* computer tape, Sept 30,1964. Causes of death were ascertained from we had not yet received death certificates for all death certificates,~but whenever cancer was men- of the men now known to have died during the tinned on a death certificate inquiry was madg_of- specified period of time. For these reasons, lung . the physician_vvho signed the certificate. In case__ cancer death rates in the study population were ol disagreement between the two sources of infor appreciably lower than those reported for white mation,. the physician's statement was accepted. males in the United States in 1964. To compensate For the purpose at hand, we only made use of data for this, we raised the rate of each individual smok covering the 52-month period beginning on June 1, ing category so that the total lung cancer death I960, and ending on Sept 30, 1964. The number of rate (disregarding smoking habits) in each five- lung cancer deaths occurring during the 52-month year age group would be the same as that of all period was divideti by the number of men alive at United States white males (based upon the 1964 the beginning of the period. This was done by five- life table and the 1961 distribution of deaths by year age groups for men in each of the following causes of death). The results of lhu.se computations molting categories: (1) never smoked regularly arc shown in Table 4. (It should be noted that 'nonsmokers and occasional smokers being com Table 4 shows only such rates as were required for bined); (2) history of regular pipe or cigar xmnk- further calculations.) mS- past or present, but never smoked cigarettes The rates shown in Table 4 were then applied to ,e?ularly; (3) excigarette smokers (including those the number of asbestos workers shown in each of "[ho had smoked or currently smoked pipes or the corresponding internal cells of Table 2. This ^Sars); and (4) current regular cigarette smokers yielded an estimate of the number of lung cancer including those who also had smoked or currently deaths expected to occur during a 52-month period ' 'ed pipes or cigars). The last of these cate- among the 370 asbestos workers classified by their V--iS was further divided by current number of smoking habits. By "expected" number, we here nSarcttes smoked per clay: (4a) one to nine ciga- mean an estimate of the number of lung cancer a day; (4b) 10 to 19 cigarettes a day; (4c) deaths which would have occurred under the mill . in 39 cigarettes a day; and (4d) 40 or more hypothesis that asbestos workers do not differ from ^Sarcttes a day. Since the men were divided into other men in respect to their lung vnneor death groups by smoking habits and further sub- rates, both age and smokin': habit*. Iwing taken 06293 448062 no ASBESTOS EXPOSURE--SELIKOFF a AL Table 5.--Observed and Expected Bronchogenic Carcinoma Oeaths by Smoking Habits* for370 Asbestos Workers men who never smoked cigarettes regularly. How. ever, considering the small number of such subjects Smoking Habit* Never smoked regularly History of pip*. c*er smoking only Hillary el ffguUf cifarttM amaklnct Observed Oeaths 0 0 24 E*p*'Ct**d Oeaths 0.0$ 0-1$ 2.98 in this study, we only.conclude that exposure, to asbestos dust does not greatly increase the. risk,of 1 inchogenic carcinoma, among,men. who..never smoked cigarettes regularly. ' Tolel 24 306 'Bjud uoen data m T.ibl* 2 and T.ibla 4. f Ineludt* eigar.ttt smok.rj who also tmokad aipa or cigar. Twenty-four of the men with a history of regular cigarette smoking died of bronchogenic carcinoma whereas only 2.98 were expected to die of it, a ratio of 8.05 to 1. From this it appears that exposure to Table 6.--Expected and Observed Deaths Among 632 Asbes tos Workers Exposed to Asbesto Dust 20 years or Longer asbestos dust jrreatly increases the risk of lung cancer among cigarette smokers. * rotil deaths: ail causes Exeeeted Observed Total cancer: all sites Exoected Observed Canssr at lunc. Inch,*, ol.ura Expected Observed Cancer of stomach, colon, rectum Exoected Observed . Cancer ail other sites combined Expected Observed Asbestosis Expected Obstrv.d Ail other cause* Expected Observed 1943-1962 203.5 2SS Total 1963-1967 19434967* 47.5 251 94 349 36.S 9$ 8.6 49 45.X 144 6.6 45 2.3 27 3.9 72 9.4 1.3 1U 29 3 37 20.5 4.5 25 21 14 35 0O O 12 15 27 167 38.9 205a 146 30 173 Now we may ask how greatly is the risk of bron chogenic carcinoma increased by the combined ef fects of cigarette smoking and exposure to asbestos, dust. To answer this question, we applied rates shown in Table 4 for nonasbestos workers whonever smoked regularly to the number of subjects with a history of regular cigarette smoking os shown in Table 2. This indicated that only 0.26 of the subjects with a history' of regular cigarette sn.nWi-^ would have been expected to die of bronchogenic carcinoma if they had never smoked regularly end had never been occupationally exposed to asbestos dust. Since 24 of them actually died of this cause, the ratio of observed to expected deaths is 92 to I (ie, 24 divided by 0.26-92). This appears to in dicate that- cigarette smoking plus occupational into consideration. The results are summarized in ^ Table 5 which shows the expected and observed number of lung cancer deaths in each of three smoking categories. ` Taking smoking habits as-well as age into con* sideration (Table 5) a total of 3.2 bronchogenic carcinoma deaths were expected whereas taking only age into consideration.. 2.3 deaths were ex* pected from this cause (Table 3). Thus, perhaps one of the excess bronchogenic carcinoma deaths might be attributed to the fact that there appear to have been proportionally somewhat more ciga rette smokers among the 370 subjects than among J men of the same ages in the general popniation. The following statements are basetl upon the exposure to asbestos dust increases the risk of bronchogenic carcinoma by a factor in the order of magnitude of 92 to 1. It should be noted that this estimate does not take current amount of cigarette smoking into consideration. .. Comparison With Earlier Findings.--As explained, we started with_rfflfohort of_<Ii'>2 asbestos insulation workers, the entire membership of the union locals on Jan 1, 1943. We havo now traced each man through April 30, 1967. Table 6 shows the observed and expccled number of deaths for each of two periods (the first, 1943 to J962, being previously reported1) and for the entire period. In respect to respiratory cancer (lung, trachea, and pleura) and in respect to cancer of the dornae-h, colon, and rectum, the findings in the two periods arc in close data shown in Table 5. Twenty-four deaths from bronchogenic carcinoma occurred among the 370 subjects compared with only 3.16 expected, a ratio agreement. Comment of about 7.6 to l. This is slightly higher than found - The increased risk uf neoplasia (mainly broncho in our earlier study which indicated a ratio of 6.3 genic carcinoma and mesothelioma) among insula to l (not taking smoking habits inLo considera tion workers reported here should be evaluated in tion). It should be noted in this connection that thu the knowledge that these men .have cnr.snamtiywly 370 subjects in this study bad been exposed tn light exposure as asbestos trades go. Primarily .em asbestos dust somewhat longer than the subjects of ployed in conslruetion work, many of the materials our previous study (the present 370 subjects are they, .use contain, little or no asbestos and others survivors as of Jan 1, 1963, of subjects in the havejmly.5%.to 15%. Conditions of work vary; previous study). these men often work outdoors unlike asbestos I Of the subjects who never smoked regularly and operators in factory work. Comparatively few dusl- those who smoked only pipes or cigars, none died pxposure surveys have been marie in this trade but j of bronchogenic carcinoma whereas 0.18 of these their results have generally been within the 5 mil / men were expected to die of lung cancer. This sug- . lion particles per cubic foot permissible limits cur gests that exposure to asbestos dust doesjot.jiuJL. rently accepted by the American Conference of crease the risk of bronchogenic carcinoma among\ Governmental Industrial Hygienists."-1,` Nor have irw 06294 448063 asbestos exposuRe-seuKCFF er m. in j- ;r i * Jfc of vs:,iever Tular ' ""loma . ratio re to '. lung : . >ron- ; ~n ef. jstoa $ rates ^ who <yf . jects % ,iown ' the king enic v; j and ;Viiatos \+ iHUSe, V' ; to 1 \ ft in- \ onal k jr o i this i 'ette I ned, tion . cats nan !*" ved .wo sly ; to ' nd nd ise .' o- a in ` !-y l- . Is S . 'n\ t additional potentially carcinogenic substances been identified among the other materials used.!* Heavier or even lighter exposure may result in 40 years ago. Youngster* who start smoking now- have a much greater chance of having both ex posures simultaneously. different degrees of risk of neoplasia. Heavy factory ^ Significance of Findings (or Asbestos W,,r!;rrs.- exposure in the past has in some instanges-cesuited The import of the data reported here seems clear. iiTconsulem_HelvTrig cancer*risk*?*-In others, para There.is an extraordinary risk of developingjuul doxically. little lung .cancer wajjseen .because,as- dying from lung cancer for asbestos workers "who Swtosis .wasso common aiid'so severe..a$ JO.cause .smoke cigarettes "regularly. In the group'.studied, deatlTo? the exposed workerb*e/ore.they.couid live # the combination of asbestos exposure and cigarette Jong enough to develdp'Iung'cancer. .Once oxposur\/ smoking increased the risk approximately 9b times ~'vas reduced by improved' industria] .hygiene piac*y< compared with men who neither work with asbestos tices, early, death "from asbestosis sharpiy-dimin- nor smoke! i^jetT and lung'cancer became .common.11 In any case, heavy exposure is not likely to be the most important problem in the future, unless Of 283 asbestos workers who had a history of cigarette smoking, 78 died within a period of 52 months whereas only 32.4 'would have beer, ex there be sheer carelessness or unconcern. Rather, pected to die within that length of time if their age light exposure, similar to that in insulation work, specific death rates had been the same as for the will be much more common, hoth in direct asbestos general white male population of the United States. working trades and as the result of indirect occupa Of the 78 deaths, 24 (31%) wore due to broncho tional exposure, as in the construction*and ship genic carcinoma. It is estimated that if these- men building industries. had smoked cigarettes but hail hot ber-n exposed to .There is another type of "light exposure" which asbestos dust, only 2.98 would have died oi bron may affect many more people than those industrial chogenic carcinoma within the same length of time. ly exposed. In the past several years, it has been If they had neither smoked nor been exposed to demonstrated that asbestos bodies can be found in asbestos dust, only 0.26 would have been- expected the lungs of 25% to 50% of adults examined at to die of the disease within a period of 52 months. autopsy in large cities, such as Belfast, Northern Of 87 asbestos workers who never smoked ciga Ireland, Capetown, Republic of South Africa, rettes regularly, none died of lung cancer within the Miami, Fla, Pittsburgh, and Montreal. This is '52-month period- (although three died of asbestosis presumably due to "asbestos air pollution" by and one died of peritoneal mesothelioma). This ^.-fibers derived from industrial "spillover" (as dust finding, being based upon the experience of only from construction sites or factory wastes) or from 87 men, does not prove that exposure to asbestos end-product use. Such community asbestos air dust has no influencejib* the risk of lung cancer pollution may be important since there is already among nonsmokwST However, it .suggests.that ex evidence that in certain circumstances, as living posure to ashTSfbs"dust floes not lead-lo an .ex within half mile of an asbestos plant or in the tremely high nskof lung"cancer among.nonsmokers. household of an asbestos worker, intimate environ The conclusions are evident: mental contamination can he associated with some 1. Occupational exposure to asbestos dust should risk of mesothelioma.13 What is not now known is be reduced* uTnslow a level'in. possible; but Liu-rc whether the minimal amounts inhaled by the gen may be an irreducible minirnumJevcTjf asbestos,.a eral public carry a similar risk.'* very .uselul material, is to be usedZat all. Such . Nor do we know whether inhalation of the very reduction in exposure will benefit asbestos workers small amounts of asbestos present in the air of some of tho future. However, wc are also concerned with communities is associated with a special lung workers who have already been exposed at signifi cancer risk in .cigarette smokers (or, conversely, cant levels for many years. Asbestos fibers will re whether cigarette smoking makes tire inhalation of main in their tissues for the-remainder of their lives. 'cry small amounts of asbestos particularly hazard- _ 2. All people incur a great increase in risk of lung pus). It will he important to ascertain whether such * cancer if they smoke cigarettes; for asbestos work cocarcinogenic or potentiating or precipitating rela ers the increase in risk is tremendous. Asbestos tionships exist because, with the rapid growth of workers who do not. now smoke cigarettes should asbestos use* (500,000 tons per year world produc never begin. Those who do smoke, should stop tion in 1930 has risen to over 4,000,000 tons per immediately. We may hope that the decrease in year now), it may be difficult' for cigarette smokers risk which results from cessation of smoking among to avoid inhaling .air contaminated with asbestos. the general public' will be the good fortune of the It may not be easy to unravel the interrelation asbestos workers as well. ' ships which might exist between community as Tbfclnvwtigittuut wrw bestos air pollution and cigarette smoking. Both cil of tho City of New York. !*y ih* Health He*erch (Sewn* asbestos exposure and cigarette smoking have a References long-lapsed period between onset of exposure and 1. SeliknfT, r.J.; Cliofi;. ,f.; ami Ifaininnml. K.l?.: Ash*>st0s Kx- occurrence of neoplasia, yet for current smokers these two exposures may not have begun simulta neously; there was much less asbestos used 20 to i poKUte rtfitl </AiUA (April (*) ICK*I _ 2, CUiirff. ami fbmmnml, K.C: ItatalSun Nr- twrefi Kxjtfwor* to A>l*r*4 hih! MomriJmltcitn** N*ut Hot J M*d (M*f<*h 1*1 rv\ i 06295 448064 112 ASBESTOS EXPO >'JflE--SEUKOFF ET 3. Hnimmmil, K.C- "b'mnkin* in ({Inlinn (n th Dxaih Itnlcx of 1.009.000 M*n snd WVmirn," in Kpid*miali>eitnt Study of Cancer and Other Chronic Discuses, iJeUiesda. Md: National Canrcr Institute. 196G. monoamph 19. pp 127-204. 4. Smoking and lltnllh. Krporl of Ilie Advisory Committee to the Sr'xean General otlhe Public Health Service, publiralion 1103. US Dept ol Health, Edcmtion, ami Welfare, 1904. 5. Hammond. E.C.. and Garfinkal. U: Changes in Cleared* Smoking 1959-1993. Amee J I'ublie Health 59:30-45 ( Inn) I'ftifl. 8. Vilat Statistic* of thg United Slatet. 1960, part A. US Dept nf Health. Education, anil welfare. 1963, vol 2. 7. Death Hotel From Malignant Neoplasms. 1060. Public Health Service, publication 1113, US Dept of Health. Edumtion, anil Welfare. 1963. 8. Mortality by Occupation and Cause of Death. Public Health Service. US Dept of Health. Education, and Welfare, Vital Sin- ti'.tica Division, Vital Statistics--Special Ht-poris. .13:323 (Ser.o 1JH3. ' 9. Kleivcher, W.K., at alt A lltnllh Survey ol I'ipt tov.nr.i> Operation.* in Conxtructine Naval VwmIs. J Induetr ttyg Tout 23.0-10 (Jim) 1946. 10. Keane. W.T, anil Z.ivnn, Nf II.: CVaif-.UionM Hnranls ol Pipe loxulators. Arch Environ Health 13:171-173 < Ai.<) liv.; 11. Doll. H.: Mortality From (.unit C.ciccr m Axbotoa Workers, Brit J fndustr Sted !2;fU-fill (April) 1013. . 12. .lacoU. G., ami An-pach. M.: I\ilmururv NwpinMa Au.i.. j Dresden Asbestu* Workers. Ann NY Acad Sc 132dl36-.'*lh tlJec 31) 1965. 13. Neeliouse. M.I,.. arid Thompson. H.:' Mesothelioma of Plrpra and Peritoneum Following K.<|x>sure to Aslnfxtos in the London Area, licit J tnduj.tr Med 22:261 -209 (Oct) IKS. 14. SelikofT. IX. el si: Asbestuais and Neoplasia, Amer J Med 42:487-406 (April) 19S7. Many, possibly most, of the words in the dictionary stand there as representatives of a whole family of forms. Not even the timidcst of the linguistically timid will run to the dictionary for encouragement when, for instance, they want to refer to a spell of "hiccuping," provided they are certain that Webster does know "to hiccup." All'the tense forms, the participles, the gerunds are assumed to ho authorized by implication the moment the infinitive is known to exist. 'Ilie plurals of nouns are similarly taken for granted, and the forms of comparison and the adverbial forms of adjectives. This phenomenon is generally covered by the assertion that a dictionary is not a grammar and that each individual entry in a dictionary stands simultaneously for all its grammatically possible forms. (For details, consult your grammar.) But is a gerund a grammatical form? Or is it a suAix-derivcd noun? I am not really looking for an answer. I ask those questions to suggest that the dividing line between grammatical form and derived neologism is both hard to de fine and artificial. If I distinguish--among men--the "hunting" from the "hunted," I have done no more than form (grammatically) two nouns from two adjectives which are forms (grammatically) implied in the existence of "to hunt." Hut if "hunting" is implied^ why not "hunter"? Why not "imntoe" yjtd "huntabifi" and "huntabilize"? The quetior\ of when a new word is amew-word and when it is merely an "im plied" farm of IT'iitiftVSrilional. term ie-inriced-man mmpltm-tfaan is-grossly ap parent Take "dehnirabitity"7T5'nn example. Can' f'ciaiin -the word is implied in the existence of "hair," or must I assume the responsibility for having spawned a monster? ------- -- --- . Or take "uneqttivocably," which indeed-was the, sinning point of all this rea soning and wonderingr for it-wns-spotted-ns a bold neologism-in <MA-fA-ia.thc sentence, "Research at the Public Health Service Hospital at Lexington. Ky, has- uncquivocably proven that methadone has all of the euphoric properties of morphine. ..." Now, clearly, the adverb "uncquivocably" is grammatically implied in the ad jective "uncquivocable," and this in tiqn is implied--grammatically of swni-gr.'un- matically or otherwise--in "equivocable." If we grant further that formations in _ "-able" of "-ible" are likewise legitimate without special dispensation, we shall conclude that "unuquivocably" is in no sense n hold departure since "lo equivo cate" is a firmly established, standard English word. But there is a hitch and a (law in the argument. "To equivocate" means "to use ambiguous language" and (by extension) "to render ambiguous." 1 fence, "equivocable" can only suggest the trait of "being apt or able to be made ambig uous," and that, I fear, was not intended. Which means, by (nongrammnticai) implication, that the discrepancy between the dbViously intended meaning of "un cquivocably" and its structurally supported significance was the cause of the un pleasant jolt experienced by the spotting reader*/ I'S.--It is of course possible, and even likely, "that "unequivoeably" was just a typo for "equivocally." ' Ackxanoku Gout; PitD 0629b a---1 a I<10 Vfii PO-1 Hn 2 ' 448065