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FILE NAME: Smoking (SMOK) DATE: 1954 Feb DOC#: SMOK008 DOCUMENT DESCRIPTION: Journal Article - Occupational and Cigarette Smoking as Factors in Lung Cancer r ftH C ttc e u t l< yw i* u zt ' o f H e a lth AC* & VEATCH oamlfieg E /iginfrt -- E le ctricity -- Indntry leyervlsiee f C em h < iU , in C ] tm4 Is t M . *dry, Ktnun City 2, M* ABOUND IODINE TESTS M ii e J f t t s r 'i l* H M fiuU , A*k f* aniHc PUBLIC HEALTH CftcJal WonAly Publication of the American Public Health Association, Inc. , YaUta 44 February, 1954 Number 2. AMSON LA808AT0RIC5 r**t PhiUdvlpM* V1 * t b 1174 V.sJb* How to U se Financial Data as a Basic RSON YENAILE, P. L mid %*4 Ckvmtcal Sa^iam* 5* Program Planning Tool A fw p W tk FW U liw , A Program D irector's G uide "i*l H n M M C k t t H u l TriMV ,, Fifth A** FHftbutgH 31. P*. KMYEY L SHAPIRO )NAL EXAMINATION SEI *ini A d rm ftistrfttio* $#pm c U tip K J4 of Public $ttt le e i H Jth Dtp M rif S yifom t Rtld . _ in Pu b lic Hefh AiJcci< *Kofl. lac l r o d v r , N f * Y o rk 11, N. V. T***JV 9*90 are eight im portant irn ri hv wki tk budget* and periotlic ft nunf i J Uatrnientt m ar benefit the mdminitlrator anti th e program he A w ls. They are not derive* to plague p rn/ettinna l p em o n n rl httl era, intieail, valued allien to p ro irasn im provem ent, outerl the writer. ITfioi to lo o k fo r and lime la as* that inform ation effectively, Is tide paper't them e. Properly understood and used. these re port* van be an effective servant. lend ing a strung hatul in changing program dreams into <>)-raling realities. When given lleeting ntleniinn. misunderstood, or ignored, tlie linanemg id program cle ment' mnv heroine tin- " m a - ie r of the htiu-f." dictating the iinlnre ami extent of professional sen io<-- un mi unplanned dav-t<-day hasi'. tint' lending to make , * long-term ronslruiiite planning pro feijj 1 `rcfraiu budgets and related periodic gram diflieult. if not impossible. laMiria) rc|mrts can be an indispensable The director should recognize in kts'tc part of realistic continuous itially that budgets and periodic, reports ' t'jrwpam planning and direction if of program financial condition are but Q.rj **4 eflrctivcly by the director and his two of the many basic tools usable in jy i..* * . planning for professional services in TVtr apitcars to be little information any categorical health program. Such The benefit * of brewers' ycid bioJotile in the literature to guide the financial reports as these assume mean ..bject to dispute. Its u be , , uracn and animal nutrition ia l f record. It is generally reeotsMf W tie richest natural source of lb itamio B complex, of nutrs ompiele protein and naturally ing minerals. But before you prescribe; bear h hat ail yeasts are not brewen' ior do all brrwcrs' yeasta m <> the higher quality and -atencr of VITA-FOOD. It pjyfc mly in its superior culture _ - J i : ilso in the skill and know how in ita production. ' - yoaluMtonally trained administrator, ing only to the eMent that they ran Ik*, m k k* a director of a bureau of ma- interpreted easily and related directly anil child health or crippled in his development of valid estimates for his special health Neither are there clear guides m ai.la. .b.le to ,he,lp ,hi.m .inte rpret .Mr. >lia|iirn is a prailiiai* -Uuli-iU and con-iill.ini. Ih ii'i-r-iiv of I'lll-liurg li Graduate School of I 'utllii- llr jllll. I'm -hill nil, 1*3. Formerly lie -eni-d a- regional ailimni-iratio mNrewthoydo- rkc,onjs-,i.ilnym. t. -]1).,,. >|. Mt(Hl.iriltlKria-i.i's llureau. >r , ',,`hv statements of financial Con- iM-fnn* llir M.*.< rn;I nu*l <.inl>! lli-ailli >rrtiim he receives in terms o f their real H -al.l, \s-.- uiion at the i-.ijility lir-l Annual 'tn lin;: in A-'w t nrk. related to his p ro g ra m , n . V.. Novcmin r 11, iv.Vl. 1-J9 ' * * ' Om. ' * c u u irw k * DeveUpweet 4 Ttthiaii^ S"**T Aston, ,rr-. Trhuxir CW `'h XVIII: Occupations and Cigarette Smoking as Factors in Lung Cancer USTER BREiSLOW, M.D., F.A.P.H.A., LeMAR HOAGUN, GLADYS lASMUSSEN, and HERBERT K. A8RAMS, M.D., F.A.P.H.A. :a. ''** l HJ^ halw4 pcnl,l,w ' < except*^ ,f Crrkr) rkf WIJIlM If, ^ Crrrknl r,!*, .N*nr. CWM|, Q4 J2;4tMl4 Stp.ii Iff tip 's New EsiiasA Jfr. l*:la-UI ^cnUtt** C Ceitbrsl PtW 'i'tuaDriimipti.m pPn,^ i i -m'Diimm y U*n- * > Spxrek 1 ). ISil. i* '>** (EUltarU), D m ld r. u -i uf a CoMrmi ic * -t s (ou.|, | vj 1 5.000 postt> this field, n honor of rthritis and a ic, or in one' must apply: for mailing I] tin Founds studies have implicated cigarette smok 7 U< fe ttr- y e a r s t u d y o f f e r s a d d i ing : 5 and certain occupations 4-- es tional evid en ce te n d in g to c o n n e c t L n r r cigarette sm o k in g w illt can ter. la a d d itio n , it t in t t e r oral fro potions that teem to Ita re to m e pecially those involving exposure to radioactive7 and chromate ores8 and asbestos'J--in the' causation of lung tdulofical rela tio n sh ip to the dis rate. Th ey peed fu rth e r stu d y , at a It suggested. cancer. However, the nunil>er of per sons known to have such occupational exposures in the United States is rela tively small. + The sltarp increase in lung cancer Mortality 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 be involved in lung cancer and thus deserve intensive investigation, and (2) to obtain data on the role of tobacco usage in lung cancer. irr than fourfold increase. In at least aae late, California, pulmonary cancer Methodological Considerations bv accounts for more deaths than does pobnonary tuberculosis, ami among aulcs aged 45-64 it causes 4 j>er cent of tS deaths. Attempts to explain this rising mor tality as spurious, e.g., as due to improerd diagnosis of the disease, do not ami up. The lung cancer death rate-- *h'p-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 be 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 i^ifiiximalion of incidence rate -- has tarrrjscd two and a half times more rapidly among men than among women. Dr. llreslow is chieb Bureau of Chronic Diseases, California Slate Department of Pub tV* ran hardly presume that physicians Litr applied diagnostic improvements m much more completely to men than lic Health, Berkeley, Calif.; and Mr. Hoaglin ami Mrs. ltasinussen are also associated with this department. Dr. Abratns, who was formerly chief. Bureau of Adult Health, Mwomen. Likewise, the increasing profati ion of lung cancer found as a cause *J death among autopsies supports the California Stale Department of Public Health, is now medical director, Health and Welfare Kiiml, Chicago Office, Theater and Amusement Building Janitors1 Union, larcal 23, Chicago, conclusion that we arc dealing with a w*l increase in the disease.1 Environmental changes apjvar to III. This paper is based on a study supported by a research grant (CS 9047) lrom the Na tional Cancer institute, PHS. and was pre sented before the Industrial Hygiene Section drr the best explanation for the oth(ethKeigAhlmy-efirri.cslanAPnnuubalilc MHiesatilnthg AinssNoceiwatioYnorakt, piwnomcnon. Previously published N. Y., November 10, 193d. 171 \ FED.. 1951 AMERICAN JOURNAL OF i -------------- exposed group came. Assuming the satin* diagnostic oiul reporting standards fur both groups. one may lluis deter111itii* liuu llie chance that a member of an e\|n*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 certain 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 susjiect 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 neve obtained implicating oeeupalions 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 Umg 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 numltcrs 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 pntions on death certificates d is e a s e npjM-ars as the cause oi 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 for cancer than on certificates when 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 daSfcSf Jk certificate data arise from the foBo^ Smtm m m i circumstances: only one occupation l>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 & 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 tbe 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 79 * 'W * LUNC CANCER VOL. 44 173 4$ f the various occ*J tificatcs where tk lie cause of deatk' lie occupations (* - may then be cor* ill death certificate ilation. If ceitta with much greats ertificates for lunr iicalrs where deaA . one ntay conclude may he involved *ivclv investigatei at.* may be credited method. However, It this use of deatk from the follower nc occupation may this is supposed U ion," it is often net nd duration in tk corded. All that blur the identii ip1aliim* from dealai f led in tlte preset mine the lifelong iaxi-u*uge history uts Iand a contra interview with tk history included tk aged, name of coo* scriptiem of dutii ids and lutzardoa he patient. loinnl and the information about m m occupation was highly detailed. A total 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 M(hrr patient admitted to the hospital to usrt the same time--of the same age 4*Win five years), sex, and race--for a roodkion other tlian cancer or a chest wa* chosen in a random manner to a matched "control." Two intertwvrrv one working in Northern CaliIwaia and one in Southern California obtained the data from the cancer patient and control patients toing the same schedule in identical Moaner That interviewer bias did not *trr into the determination of tobacco* M ft history seems likely, among other rvaaon*. because the results closely parallel those obtained in other investiptllons where such bias apparently was _eulnded/'* and because the results for Aw two interviewers were very similar. k W difficult to conceive how inter* sirwtr bias might have affected the mpational data, since both lung ranerr patients and control patients rationed hundreds of occupations and . Soar of these was suspected by the intrrnewrra. Preliminary findings were V * from the interviewers until the nd 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 data 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 coopcnths ^ lilion permitted tie 'ion with each vo hour* or mon 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 Tit 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 AMERICAN JOURNAL OF PUBLIC HEALTH T able 2-- Sex and R ace D istribution of Lung Cancer l'atirnt* and Control* Sex *nd Race Adeno carcinoma Cases Other Types of Carcinoma Total Control* gg Total Total 46 472 S18 518 Sj Total male 42 451 493 493 . White 41 420 461 461 | Negro 20 20 2D f t Other 1 11 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 4*trtii (or the rrie*. TVio suggesti Findings on Smoking ***** only is ( tories of having smoked cigarette!^ 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 tkST'` y*. hypothe controls gave a similar history. Nomdfc!^* ^ g g ^ g the f greater frequency of tobacco usage itfla ^ - | 0( tj olltcr forms Ipipe, cigar, chew, snuff) occurs among the lung cai patients when compared with the w yf.-: ^^ocarrinom a trol group. In fact, o3 of the cot**, 552 MOM wherea group used tobacco in a form other tW cigarettes exclusively; whereas only 12! * P** m il) of ( earcino of the lung cancer patients did -! W - m wytiamous, fel did not t lTt- - Om rommon' of expo T able 3-- T obacco U n*t D uring 20 Year* P rio r to Study R eported by L ung C ancer Patients and C ontrols T U S-- Axe Case? Co Contrdi | Manner of Using Adeno Other Types Tobacco carcinoma of Carcinoma Total Teul | Total Total not smoking cigarrties 16 472 518 Sit : f V a n tti Smoki t karacteriatics ' 6 28 34 w . No u*e of tobacco 4 15 19 Si Tobacco other than - 3p | L * d cigarette mc cigarettes, only 2 13 15 <8 ' ><* IS yean ot i f b t a IS-2J Total smoking cigarettes 40 444 484 394 " ? ' 8*aa 25 year* of Cigarettes, only 31 298 329 240 1 -* before bre Cigarettes and other 9 146 155 154 1 |*V * t tle rough" LU.NC CANCER VOL 44 17S Amount of C igarette Sm oking D uring 20 Yearn P rior to Study R eported by l.nng Cancer Patient* anil Control* Packages of Cigarettes Smoked per Dty Number Cases Per ernt Controls Number Per cent Tsui 518 100 518 100 None 34 7 124 24 19 4 so 10 M H- 71 14 105 20 1 - 304 59 199 38 >Sj 2 at more 80 15 22 4 Not recorded 10 2 18 3 timl for the nonusers of tobacco in 6r two series. Tbit suggestion of an effect by cigmittrt only is consistent with other in* wdigitions in the field. Some support hr the hypothesis that cigarette smokWf affects the development of epithelial tarrianma of the lung more than adecarcinoma may be noted. Six out W 46 (13 per cent) of the cases of fcjroocarcinoma 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, utidiflcrcn- did not smoke cigarettes. One commonly used measure of the asnunt 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 Mai 9* 'IS 24 56 , 68 94 >0 54 TiU 5-- Aae of B eg in n in g C igarette S m oking, S m o k in g H ab its, an d " C igarette Couch" Reported by Lung Cancer Patients and Controls G rum e Smoking Ouneteristics Number Tsui 518 Tui cijirette smokers 481 Br(jn 15 rears of age J66 Begin 15-24 2H6 Begin 25 years of age .12 *U!uW 419 "SmAe before breakfast'" 373 "G rum e cough" 201 Ca-es Per cent lSa*cd on Cigarette Sntukrrs Only 100 34 59 7 93 77 12 Per cent Rased 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 at PtC# iSf-j l;i { H*>*-v. As. F E B , 1954 AMERICAN JOURNAL OF PUBLIC HEALTH T a b ic 6 -- E stim a te d P re v a le n c e R a te s * o f L u n g C an cer p e r 1 0 0 ,0 0 0 Maid o f S eleelctl Ab nm l V a rio u s C ig arette S m o k in g H a b its a! Ion _____ _ _ &t liv Number Estimated Prevalenre Rates Quantity y-nmked Daily t Relaths fejeTtmiio? Prevalent*! Ta n rt Lung Cancer Control All Quan Heavy ** tities None Heavy . ^V t sm oking la the l These Patients aged 50-59 years I. Doll ami Hill 276 275 94 42 2. Wynder and Graham 258 210 117 47 jc& f W J hi csteg 7 13 (fir smoking, 4 27 njz smokers, 5. Sadowsky, Gilliam, -|W W tWy would and Cornfield 4. Present 198 208 87 44 12 7 < 1 aaftsirtM length of t 213 213 102 46 6 17 4 U a | rsneet Patients aged 60-69 years 1. Doll and Hilt 197 199 137 63 2. WytiJer and Cruliam 187 100 138 70 3. Sadowsky, Gilliam, and Cornfield 76 71 44 71 C JWoy isV* f cigsrv 0 , # #affc BmokeSS. (Sue 5 29 ttf sy.) 5 9 fUeenef. sUltsiic 4. Present 168 169 433 78 17 25 'n %E n i ir d t c t n ii a | ( iW < t M 4 Cor*&elt).u D a u tor muJ k i ot Dll w 4 U til; W y a 4 u $*4***h7, GilU*d, aud Corni)d irw tl latter paper.** f (/u a a iliy i k 4 daily, < u p t lot p f t m t tty J y , io all form* mt m o k i t | etp rom t4 a* c i i m t t H , wkfc cif*r f * t n d t iW ir i^ n iv ile a it in ciru t io lU w t: 1. Doll a*4 H ill-*) o*, ! tobacc* a weak s 4 for tisla Imrsligstio to mske c fAkl so aiuwer to a d ay; 2. W yadf aad Crakaa*-- I cifar s r 5 cifarettra, 1 pipeful s s 2% t>*areit*t; am4 i . Sadowakf, C em kcM -- 1 cifar -- 14 cifaretiea, 1 o t. pipe tob acco =s 24 cifarcttce. 4. For pre*e *tdy, quantity -- w d S f c does ci tariudee only eifarette amoktaf. I Relative pccealewea la the ratio: llea v p ^ r a ia aato o f b**y tm ekera/rtte i e t t | aeoam ekete; all feaaddm omuiif mek*ro/rte am eof neoamokata. Heavy tm o k i* | ia defined a* the fello w lo f som ber of cifarettee or l y t i t i l e t u ot eifarettee per dayoC aad H ill--*50 or m ate; 2. W foder aod Craham--3S or more; 3. Sadewtky Gilliam, aed Carafieid--41 ar H | 4. preaeot O iu ip -4 4 or more. 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 m i steadily with the amount of cijs; smoking. One can hardly escape! 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 Aatbors, edc .Skip captain Clerks, gem ' Cantauers . Salesmen to % iirr tmi PolK-rmcn tr Animal ami Farm hantir. C ra n il wo*- rlwwhrrc Painters, e tn Brick and ai<< Cna.iruclion toscomolive fi Hi Attendants, li Mechanic* aii SUMI SlM.U ruth* *m itwi4*4 *<r4u P . Cat V . Cr%k*a; ad tamikUa m LUNG CANCER VOL 44 177 BUfihood of lung cancer? Further, *44 is that likelihood in absolute tn a ! To answer these questions ; Mautelr would require that records of dptette smoking for large numbers of prwtna in the lung cancer age be availed. These persons would then ! placed in categories with respect to fjprrtte smoking, e.g., nonstnokers, m in tit smokers, and heavy smokers. fWUy they would be olrserved for a Arimt length of time to determine the to of lung cancer among the various a*yories of cigarette smokers and the aHoaokers. (Such studies are now m in way.) However, statistical devices have been Jtmloped for data such as those in the j**it investigation which, if one is wixar to make certain assumptions, JW an answer to the question, how m *i times does cigarette smoking in* errase the likelihood of lung cancer? Application of Cornfield's formula M> ls to the data from four studies, including the present one (Table 6 ), indicates that for men aged 50-59 the prevalence of lung cancer is from four to 11 times as great among smokers as among nonsmokers, and from seven to 27 times as great among heavy smokers as among 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 tients are a representative sample of all lung cancer cases and the controls are a representative sample of ail other per sons in the general population. Findings on Occupaiions As noted earlier, the records for lung cancer patient and controls showed all Table 7-- Tw enty l 'r r cent S am ple from C om plete List o f O ccupational G 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* cigsrettt .scape the lill * that important carcinoma .ccent coa*.-j amount, I J king ia I n .1 prospectin' know ho* oping lung 1) smoking. :tion 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 1SS Canvassers anti solicitors 3 11 ISO Sslesnien to consumer- 7 4 777 Waiters and waitresses, except private family 14 10 !66 Policemen and detectives, public service 6 3 307 Animal and livestock farmers 6 5 < 317 Farm hands, animal and livcsltx-k 10 10 433 General woodworking: oertipulimi-, not elsewhere classified 8 7 j 516 Painters, except construction and maintenance 3 6 j 571 Brick and stonemasons and tile setters 5 1 | 532 Construction occupaiions, not elsewhere classified 45 25 j SC Locomotive firemen 3 6 1 - VjO Attendants, filling stations and parking lots 10 9 , $13 Mechanics and repairmen, not eUewliere classified 15 lb TUto: $ * ?( rm adoaiy **W<d from tko 9) u rru |t iiM tro o p * v b ic b o i l (bo tU tc d frcqr*or> 4 m(mo t ^ t i f i M d {< I n o 5 ( m i o r 5 eo a tro U v illi ) y t a n a t m ata r m p l o r o n t ) . O ctopo- io n to 3'digii tr|iM i U ilw O i-ttM iry of O teapttiam al Title* |! n d tt l.) , V**Moieo, 0 . C .; U. S* * p lo y e * bv ro ic e. I f l f . b '.s ^ iitflf | | m *f*1W 41 i ITS IV.i:,. AMKKH.VN JUli'tiNAI. IH' I't iU.IC I l K U . T l i Tiilflr H-- OcriijisiiiHi ` in AAliirh ihr l*'rri|tinr* nf .1 ^i*:ir Employment Anions: ( '.* \\ n* nt T*ir* a* ^ (rrnl u A nions Ouitrol** ample, one occ ' 530 (plumlicrs . fitters) showed r,fslt Kill)laa\*ai in 'with a fivc-yc Occupation O ir u ju t inn at .T A i-afv ' Examination c records rcvcalc Ca-r CControls jthe difference 1 ;series was due 016 Enpineers, civil 138 Slock clerk.2f>6 Policemen and detectives, piililie service 430 l.umliermen, raftsmen. ami wood chopper473 Machine *hop and related occupation-;, not . l 7 3 t. 3 ii .1 ihad a heavy e iwas also noted involving asbci iqucntly in the elsewhere classified R 3 eases than amo 485 Welders and flant<- cutter520 Occupations in production id petroleum 523 Construct ion maeldm-ry o|N-rnior<, not elsewhere classified 524 Brick and stonemasons and tile sellers 10 1 f ' ;tory of controls. . n .including steam i 3 r. u d boilermake .> 1 re to asbestos- 538 Brakemen, railroad 10 5 570 Firemen, other than process firemen 11 2 573 Cranemen, derriekmen, hoist men. and -hmrlmen 15 6 575 Drillers, extraction of minerals and construction 2 times among tl time among the i Table 9 prese lions grouped * Ocrvpatioaa cla*i&*4 arrordine to tlir Dictionary *f Ocr up.stioaal T.l* Crt.i d.). significant ^xpo V a h in fto n D . C . : U . S . E m p lo y m e n t S e rv ic e . 1*#10. I n c lu d e s o n ly o c r u pal ^n* a *!> t UC S c a a ta w ith 5 year* o r m o re ! rmpl>% itifM , F- Vers in each of the differences ] troU appear to ii occupations followed and llieir 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-andduralion category. the numbers pertaining to any one ocrupation would be lr-s impressive thu in the case of cigarette smoking. How ever. the frequenev with which the lllfl| cancer patients had pursued certain oc cupations wu< substantially greater tlm the frequency with which control [* &tcd. It is o nreral 0f those differences invol particles and ft elallic corabus' fends to corrobc lfynder and Gra Table 7 presents a random sample of tienls had pursued these same occnpi- these occupations and the number of lions. _ patients and controls who at some time The occupations for which the fre Table during their work history had been en quency among cases was at least twier 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 coi among the 518 controls, nine had been which was riot devised to reflect c< 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. Ftuilts Electric h Occupation 4 same logical significance, as such fre analysis therefore included the is 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 i> among both case and control groups grouping of occupations according h Comtruct i Cook*, cot than is any single occupation. Hence, possible common exposures. For o * Ore*patio* 4 U iM fs a a ij ii l.UNr. <c.:\.N\n(,ur.:ikt vV<(u,,,, -iiii t:n to any one W> s impressive tb* le smoking. J ith which the Inf*? ursued certain * itially greater lh which control hese same o<xtttw <v lor which the lm ' ' was at least tvW controls, using tW-. ition category >ie 8. Such a UW 'ws the occupatM* | <>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 H*is, \ posures. For " byfc, one occupational group, tmmbrr X* Iplombcrs, gas filters, and steam Xtoni showed 16 cases and 10 controls a five-year employment history, taaaieation of these 26 individual jpaafc revealed that substantially ail fcfcrcnce between case and control feta was due to the steam fitters who a heavy exposure to asbestos. It he noted that other types of work lag asbestos occurred more fre- 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 fa* ong the controls. -- 9 presents the data for occupa- pouped according to possibly ^ fra n t exposures. Although num- Vi la each of the categories are small, ill ifrrcnces between cases and con- Ubippear to implicate the occupations Jt is of interest to note that i of those with the- most striking ffm scn involve exposure to metallic and fumes and products of Mdfic combustion. This observation th fc to corroborate the suggestion of and Graham 13 that "hot metal" ix-cupotions 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 sjtccial 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 llicse. It may be noted that 77 persons with lung cancer had an exposure of more than five years to suspect occupations (unduplicatcd 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 present data might be expected to throw some light is the extent to which ciga rette smoking and occupations operate Table 9---- G ases n n d C o n tro ls E m p lo y e d f o r ut L east 5 ) f a r s in Selected O ccupation C roups * Occupation 1$ l tt'eldcrs and sheet metal workers doing welding :J~ L Stesm fitters, boilermakers. 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, oilers and wipers :"h t Construction and maintenance painters dt X Cooks, commercial (excluding cannery cook*) Persons Employed in Occupat ion at Lea*t 5 Years C a*-o C.ontfols u . 2 1ft 1 5 1 9 12 h 22 12 3.'> 21 jrrm p * rrw rtjin f t<* rn n m u ii jh ri nM ( ii n i n i liM 'o f m * SI , e i h i b d r . t i t? hi ' MDVT - ; 1; ! . r . - 'i f:rA , 3: 7 ` ij :y ] ; *\Y IS # t.!l> V I 180 FEB., 1954 AMERICAN JOUKN\ L OK PUBLIC HEALTH Tabic 10-- Exruui'Ir o f A<lju**imcnl for Sm okine Applirvl lo W'clilcrf ami Sheet Mctni Workcm Doinp W cldiri; None Packages ot CigarcHcs Smnknl |-rr Day V* -- 1 - 2 or more Nni re* Total how L* group lung ci smokin Conclu All cases 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 80 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;:83 10 493 18 493 28 986 0.357 0 14 0 2 0 16 0.0 9.002 9.003 E l p M l v d p r t p t f t l M i cm B i f w d d f t i = ---- 1 s 0 .S 6J H 14 Observed praptrtiM ( eases iaw( veUieras --= M?S 14 14 N ia iy * 6 * p a r e r a ! c e a f id * * * * Jia tita ( fa r the pr<*?*rtio -- z s (0 .6 1 7 , 0.<*6D -- a ta tia iira H y tic n 'b 'a o i at IS ym caul leval. 16 Ftm alaa rtrla d e iJ from total group, awly mole* a r t ia eiu d ed in g roups to which tr*t wss applied. t O btained by applying tk o p ro p o rtio n o( ca*e among to tal res and cn n irn la in each m u tin g c n irio ry ta lb num ber of w aidart in that am oktnf category (line No. 4 X lin t No. 7]. ! H ald, A. S u tia t'c a i T ab les so d F onaw lat. New Y o rk : Jo h n W iley. 19*3. N o te ; T bia teat also was app lied to ail other o ccupation group# a/towo in TaM a 9. T he group " r te a a fitter* b o ilerm a k ers, asbestos woikara** w ta on th a b o rd erlin e of ta tittie a ) a ifn ib ra o e r at tlie 95 p er re n t level. None af tfci a tb e r gm ops m et th e 9% p e r r e n t level o( atatiatieal aignifieanee. The c another connect! smoking land Joi "so stro within t word." * with he; ethics of and mec Further exact cor Ur, araen aibie., The df 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 differences might arise from chance variation more than five times in a hundred. However, all the occupations listed in Table 9 deserve intensive study t8 determine their precise relationship ta lung cancer. One important step is to assemble populations of individuals ea> 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 the rate for the correspond ing age-sex group in the geneni population. One may thus determine Journal 2! Adoendi on the conn an cight-pag Journal, Ray of health ed January issc education, L; been the autl fears, it havi r i l.UNC C.ANCEK VOL -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 i>ierhnni>tu responsible should lie identified in order that protective meas ures may be introduced. IU 1 t.K I.M .t.S 5tal Conclusion 1. M. f.., I*" U, n ., n<l * * > . E. L. C*n^*f I th f Lang in R rU linn in Tebncr*. B ra. J. Center 5 :1 , ItSI* The data in this study constitute still 2 . S*fcr*k. f U Baker. U A .. Ballard. C. TV. tm,\ Dolgoff. S. Tohaere* S m nktftf * an f.t i<*lv*ir*l Fa* another link in the chain of evidence connecting lung cancer with cigarette leaf m D iaeaae. C R * * * * c b 10 49-5A. 1950. 3. Wyndrr, F.. L., *ni Grahim, E. A. Tr*L*-ro Smk- in f I'ocnrMe L liulnfic Fartne m llrmc smoking, evidence which the New Eng land Journal of Medicine notes to be "m strong as to be considered proof within the everyday meaning of the C*rcirw*ti. A Study of 6 6 i Proved Cawea. J.A.M .A. 143.329-336. 1950. 4. Doll. R.. H ill, A. R. A Stud* thr Aetml^jy of Careinama oi the* L on f. B n t. M. J. r iI 'I -I J 8 4 . 1952. 5. L*tn. 51. L., (foMaintn, H ., and Cerhard' , T- R. word." 14 It is time for those concerned Canerr and Tobacco Smohin*. A PtehmiDory R<* port. J.A.M .A. I O :A36-33f, 1930. with health education and with the ethics of advertising, at least in health *. Harper. T . C. (Vep*ton*l Tumor* and Allied Oiortvrt. Sv<inc6elU , H L : Tknn. 19\2. 7. RoMoak), O., Sinpn. E. and Schraorl. C, Die and medical journals, to lake note. Further investigation should seek the Derfkronkhtii dor Errbcteleni# in Sckoeebcrf La Sachaea <*4Shneebercer L unfeabreba"). Zt*ehf. (. Krebaforarh 2 3 J 6 0 -6 6 t, 1926. exact component of cigarette smoke-- Ur, arsenic, or other--which is respon I- Mncklc. V ., aad G frfo fio a a , F. Cancer of the Rrcptrttnry Syctcvn in United Statea. Pub. H ealth R ap. 41:1116-1127, 194*. sible. The data also suggest that several occupations (Table 9 ), in addition to 9 . GWyn*. 5 . R. Pn*u<x*nio#i|; liiatnlnfir*l Survey of Neropey Material la 1205 Caae*. I^tiret 1 :810, 1931. 10. Doll, R. Oroaabial Carcinoma: Incidence and Aeti. o lofy. Part t and Pari II. Brit. M. J. S21-S27, those previously identified as having an etiological relationship, may be involved M 5-390, 19.53. 11. C om beld. 1. A Method ol Ertirnatiitg Comparative Ratea from Clinical Data. Application to Caoeer of la the development of lung cancer. These occupations should now be in the I^ini, Bren*t, and C erais. J. Rial. Cancer Inat. 11 :l?f>9 1275. 1931. 12. Sado*ky, D., Cilliam , A ., and Cornfield, J, The tensively studied to determine to what extent persons engaged in them suffer a special risk of lung cancer. There 5ttaticaJ Aaaoeiatioa Between franking and Car* tin note of the L unf. tbtd. 1 3 :1237-125f, 1953. 13. V yndee. E* L.. and Grnham. E. A. E liolo(ie Factora in Bfrmchioceatc Careiooma with Speeial Refeyenee to Indoatnai E*pn*ure*; Report of 837 l'roed Caaea. after, if an etiological relationship is elearlr established, the precise exposure Arch, laduat. ]f f, A Orcup. Med. 4:221, 1951. 14. Editorial. Cancer of the L nnf. New Enfland J. Med. 249:4*5-4*6. 1953. J 'V MtJ i. J-hr*. 3. . (V! v ' ) 1`i M p m mm 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 tire 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 pars, it having first appeared under his by-linc in March, 1926. a me ......1 '! * V '! i l '.e:/*l-*C* tiF-nrxta