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FILE NAME: Friction Materials Standards Institute (FMS) DATE: 1976 DOC#: FMS043 DOCUMENT DESCRIPTION: NIOSH Booklet - A Guide to WorkRelatedness of Disease t'vbfic Health Servie* Center far Disease Contra! National Institute for Oecusation*! Safety and Health f A GUIDE TO THE WORK-RELTEDNESS OF DISEASE . Marilyn.K. Hutchison, M.D., Editor U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Center for Disease Control National Institute for Occupational Safety and Health *1 1976 f m *ni* 7 n I H*# . VJ.5. P rinting Q l t u ' , W )A i K ( I a . O .C . JfU Q J V This Guide is based upon the report submitted in accordance with NICSH Contract No. 210-75-0075 Project Officers: Marilyn K. Hutchison, M.D. Stanley Kusnetz, M.S. D H E Y V (N10SH) Publication No. 77-123' i 11 PREFACE The goal of the National Institute for Occupational Safety and Health (NIOSH) is to protect the healthend cafety rf working men and woman. Within the context of this program are NIOSH efforts that are directed toward the identification of those disease conditions that are causally related to occupation, as necessary prerequisite to their prevention. This guide is presented primarily as an aid to State agencies and others concerned with occupational disease compensation. The Guide presents one method for assembling and evaluating evidence that may be * relevant in determining the work-relatabness of a disease in an individual. Information on five disease-producing agents is presented to illustrate the decision-making process. It should be noted that such information may not be complete and does not necessarily reflect the most recent data regarding health standards and epidemiologic studies. NIOSH will'welcome suggestions for improvement of the Guide based upon experience with ios use. i i i ABSTRACT This Guide discusses various factors associated with establishing the relationship between disease and occupation. Prepared as an aid to State agencies, physicians, and others concerned with workers' compensation for occupational disease, the publication describes a method foi collecting, organizing, and appraising medical, occupational, and other evidence with the aim of determining the probable work-relatedness of a given disease. Illustrative material on five disease-producing agents is included. The Guide also contai-ns a list of occupations with potential exposure to selected agents, and other information that may be useful to those with decision-making responsibility in cases of occupational disease. ! 1 TV \ ASEEST03 Introduction Asbestos is a mineral fiber, and is the name given to about thirty silicate compounds. Of these, only the following -5 are of significance in industry: Chrysotile (white asbestos) Amosi te Tremolite Crocidolite (blue asbestos) Anthophyl1it Chrysotile accounts for about 97 percent of all the asbestos used in this country. Asbestos .is widespread in the environment because of its extensive use in industry and the horns. Over 3,000 products contain asbestos. Because of this wide usaqe, it may be difficult at times to 'determine if a disease arising from asbestos is occupational in origin. .For example, the air of some relatively new apartment buildings has been found to. contain more asbestos fibers than the maximum recommended levels in industry. The source of the fibers in the apartment buildings is the insulating materials used in the ventilating system. Exposure to asbestos can produce a lung fibrosis called asbestosis. The onset of asbestosis is usually gradual, developing over a period of 10 to 30 years of exposure to significant concentrations of asbestos. Occasionally, from very massive exposures, it may develop more quickly. Asbestos is also a cancer producing agent (bronchogenic carcinoma, meso thelioma) and can cause certain specific skin diseases (asbestotic subcutaneous granulomatosis and asbestotic cutaneous verruca). Heavy exposure to dust containing asbestos can cause skin irritation, Epidemiologic studies (experience with groups of people) and aninal studies have shown that increased exposure to any of the types of asbestos increases the risk of lung cancer (bronchial carcinoma). This carcinoma appears to be related to the degree of exposure to asbestos, the type of asbestos and cigarette smoking. It is also significant that cigarette smoking in men and women greatly increase the risk of lunk cancer in those who are exposed to asbestos. Smoking is a factor that should be considered when (determining whether lung cancer is caused, wholly or in part, by an occupational exposure to asbestos. Mesothelioma*- a rare malignant tumor of the membrane which lines the chest cavity and the abdominal cavity, is occurrir.a with increasing frequency in workers with exposure to asbestos. The development of this tumor apparently is not related to one amount of asbestos inhaled and it is found in persons not having asbestosis. Levels of exposure which are within accepted standards for protection against asbestosis, may not 23 protect against mesothelioma. An increased incidence of malignancy of the stomach and colon has been reported among insulation workers using asbestos. Occuoations with Potential Exposure to Asbestos Acoustical Product Makers Acoustical Product Installers Air fi1ter makers Asbestos-cement products makers Asbestos-cement products users Asbestos-coatings makers Asbestos-coatings users Asbestos-grout makers Asbestos-grout users Asbestos-mi 11 board makers Asbestos-millboard users Asbestos-mortar makers Asbestos-mortar users Asbestos millers Asbestos miners Asbestos-paper makers . Asbestos-paper users Asbestos-plaster makers Asbestos-plaster users Asbestos sprayers Asbestos workers Asphalt mixers Automobile repair garage workers 8rake lining makers C-uilding demolition workers Carders (asbestos) Caulking compound makers Caulking compound users* Clutch facing makers Cobbers- (asbestos) Construction workers Crushers (Asbestos) Fiberizers (Asbestos) Fi reproofers F iremen Furnace filter makers Gasket makers Heal resistant clothing makers Insulation workers Inert filter madia workers Ironing board cover makers Laboratory hood installers Laagers Paint makers Pipe insulators Plastics makers Pump packing makers Roofers Roofing materials makers. Rubber compounders Shingle makers Ship builders Ship demolition workers Spinners .(Asbestos) Talc miners Talc workers Textile flameproofers* Textile workers Undercoaters Vinyl-asbestos tile makers Vinyl-asbestos tile installers Weavers (asbestos) Medical Evaluation (Also, See Decision-Making Process) In addition to the usual medical history, the following should be considered * 1. Any history of diseases of the heart or lung or abnormal tissue crowth Should be carefully evaluated to datarrr.ine the relationship between the previous disease and the claimant's present condition. 24 s 2. A respiratory questionnaire, a sample of which is she Appendix, can oe useful in evaluating the extent and of respiratory symptoms such as: - breathlessnessI - phlegm (sputum) production - chest pain - cough - wheezing in .ertance Asbestosis Shortness of breath upon exertion is-usually the first symptom, frequently accompanied by a dry cough. This symptom develops after several years of progressive pulmonary fibrosis. As asbestosis progresses, the following signs and symptoms are observed: - cough with production of sputum - anorexia (loss of appetite) - -secondary respiratory infections that are difficult to control - rapid breathing - repetitive end-inspiratory crackles (crackling sounds heard in the lower part of the lungs through stethoscope when employee -completes each of a series of inhaled breaths) - orthopnea (breathing difficulty in a recumbent position) - cyanosis (change in skin color to-bluish, grayish, slateliks or dark purple) decrease of chest expansion - digital clubbing (rouncing of the ends, and swelling of the fingers and/or toes) - sequelae (other resultant diseases) including cor pulmonale (right heart failure), branch ogenic carcinoma (lung cancer), stomach or intestinal cancer, or pleural carcinoma (cancer of the membrane lining the chest) FibrOsis results in alveolc-capillary block (impaired ability of the lungs to transfer oxygen into the blood). This impai rrr.snt is often more severe t.oan is indicated by chest x-rays. 1 25 Mesothelioma In cases of mesothelioma,' the rare malignancy noted above, there may be a long latent period, as much as 40 years, between initial exposure to asbestos and the development of the tumor. Mesothelioma of the peritoheum (membrane surrounding the abdominal organs) is usually accompanied by abdominal swelling and pain that is not concen trated in a particular area. Signs and .symptoms of this type of tumor (which may be associated with asbestos exposure) include: - weight loss - obstruction of the bowel - excessive accumulation of fluid in the abdominal, cavity (ascites) is almost always present This malignant tumor of the peritoneum may spread to the chest cavity. With mesothelioma of the pleura, complaints include chest .pain and breathlessness. Signs and symptoms of pleural meocthelionv: include: - pleural effusion (accumulation of fluid in the space around the lungs) - the tumor may grow outward through the chest wall in the form of a lump beneath the skin (subcutaneous lump) - the tumor may spread to involve bone, lymph glands (nodes) mediastinum (area between the right and left lungs), and pericardium (the sac enclosing the heart). As a result, the supraclavicular nodes may become enlarged, ribs may develop tumors, and obstruction of the superior vena cava (major vein draining the upper portion of the body) may occur. - in addition, pericardial effusion (fluid in the heart cavity) may occur, causing tamponade. Laboratory (See Decision-Making Process) Additional tests which will assist in arriving at a correct diagnosis are: Chest X-rays Findings should be classified according to the ILO/UC 1971 Classification of the Radiographs of the Pneumoconioses. (Appendix B) Findings for asbestosis vary, but the usual picture shows a density in both lungs, with the lower one-third of the lungs involved. In the affected area there is a "ground glass" appearance. j 25 As asbestos is progresses, more and more of the lung is involved, except the-apices (tips of the lungs). The X-rays will shew gradual obscuring of the border between the lungs and the diaphragm. It may show shadows from the presence of nodules. X-ray findings usually will show the following as the asbestosis progresses: - reduced radiographic volume - formation of cysts combined with increased size of the heart, dilation (enlargement) of the proximal pulmonary arteries (arteries which lead from the heart to the lungs) Luna Function Tests Reduced lung capacities and other lung changes do not differ from those resulting from other forms of lung fibrosis, both'occupational and nonoccupational. Therefore, the results of lung function tests alone or chest X-ray findings al,,r.a dc rot lead to diagnosis of asbestosis Asbestos bodies lymph nodes indicate exposure, but not necessarily asbestosis. - Asbestosis causes a reduction in the vital capacity (VC) of the lungs' . and a reduction in-total lung capacity (TLC). These capacities are further reduced as the disease progresses. - The residual volume (RV)of the lungs will be normal or slightly increased. - The lungs' diffusing capacity for carbon monoxide (Dj_) will be reduced. Other lung function test results which are found in asbestosis include: - Increased minute ventilation (amount of air breathed in one minute) - Reduced oxygenation of the arterial blood (arterial hypoxemia) --Increased static transpulmonary pressures - Decreased lung compliance An exercise test will result in an increased amount of air required during physical effort, decreased oxygen in the blood, leading to cyanosis. Scutum Examination Asbestos fibers cr bodies may be found in the sputum.. These indicate asbestos exposu-e, but not necessarily asbestosis. 'here cancer cells are present in the sputum, anc- chest X-ray findings are normal, bronchoscopy may be necessary to confirm and locate the lung tumor. 27 Skin Tests--The follow:re tests should be performed by the physicien to exclude possible infectious diseases: 1. PPD (tuberculin test) 2. blastomycin 3. histoplasmin 4. coccidicidin Epidemiological Data Various epidemiologic studies have demonstrated the relations:'!'?? between asbestos and lung disease, including mesothelioma, in such trades and occupa tions as mining, insulation installation, textiles, paint, electrical incustries, and many other occupations as a result of the widespread use of. this substance. The available information indicates evidence of a dose-response relationship for asbestos exposure and the risk of asbestosis and/or bronchogenic carcinoma. However, much of this information is epidemiological in nature and chere is little correlation between epidemiologic data rvi environmental exposure data. For this reason and others, including the long latent period for the development of carcinomas, it is difficul to deye,-;'p a spec1~ic dose-response relstionsnip. ims snou; ,e taken m t o cor.:;i dora tier. ',,'hen referring to the following material: 1 Entsrline has reportac an exposure-response relationship between asbestos exposure (evaluated i s millions of particles per cubic foot years) and the risk of malignant and normalignant respiratory disease. Enterline's data indicates that the risk of respiratory cancer increased from 166.7 (standardized mortality ratio) at minimum exposure to 555.6 at cumulative exposures exceeding 750 million particles per cubic foot years. Enterline's data is summarized in a table by NI0SH2. Murphy^ reported that asbestosis was 11 times more common among pipe coverers in new ship construction chan in a control group. The first asbestosis was found after 13 years of exposure to an estimated cumulative dose of about 60 million particles oer cubic foot years. After 20 years, asbestosis pre valence was 33". Murphy reported no asbestosis for men exposed to 60 mpocf years but 20"asbestosis in men exposed to 75-100 mppcf years. Murphy reports atmospheric dust concentrations ranged from 0.3-10.0 nnncf depending on the different operations evaluated. Asbestosis was considered present if the worker had at least three of the following: vascular rales in two or more sites, clubbing of the fingers, vital capacity of less than SOS predicted, roentgenography consistent with moderately advanced cr advanced asbestosis, shortness of breath on climbing cne flight of stairs. a The Pennsylvania Heoartment of Health reported a study of asbestos dus concentrations in two plants (one studies from 1930-1567 and tne other 7nom 1948-1962). 64 cases of asbestosis were reported. In the two Giants, the study indicates that the air concentrations of particulates were genera lly less than five mppcf and in many cases less than two mppcf. Epidemiological evidence is also available relating^the development of mesothelioma with exposure to asbestos. Selikofth.o reported 14 deaths 28 from mesothelioma in 532 abestos insulation workers from 1943-1958. No deaths from mesothelioma would be expected from the same number of individuals in the general population. Evidence of Exposure Historically, there have been two air sampling and analysis methods to determine the quantity of asbestos' in the workplace environment. The earlier light field impinger count method allowed only a measure of the overall dust level in the air rather than focusing on the amount of asbestos fibers in the air. The current fiber count method, satisfactorily determines the amount of asbestos fibers in the air. It is performed by collecting airborne materials on a membrane filter and then counting- the fibers using a phase contrast microscope at a 400 to 450 times.magnification ratio (400X450X). Asbestos fibers occur in varying lengths and diameters. As of the publica tion of the guide, the Occupational Safety and Health Act (OSHA) establishes maximum allowable limits for asbestos fibers greater than five micrometers (urn) in length. OSHA limits such asbestos fibers to no more than five fibers per cubic centimeter of air (based on an eight hour time-weighted average exposure). OSHA further requires that no workers be exposed to more than 10 asbestos fibers (greater than five urn in length) during any one 15 minute period of time. For samples collected by the field impinger count method, results may be compared to the pre-1970 limit (TLV) of five million particles per cubic foot of air. Occupational exposure to asbestos fibers five um in length or greater, at quantities averaging more than five fibers per cubic centimeter of air or frequent exposures to mere than 10 such fibers during a 15-minute period of time is evidence of a possible causal relationship between disease and occupation. Toxicological (See References 1-6, Appendix A) Conclusion The diagnosis of occupational asbestosis is based on meeting the following criteria: 1. Confirmed history of occupational exposure to asbestos. 2. X-ray findings compatible with those indicating asbestosis accordi to ILO/UC 1971 "Classification of Radiographs of the Pneumoconioses 3. Pulmonary impel rrr.ent, particularly a decrease in lun diffusin capacity and an increase in alveolar-arterial oxygen cifferenc 29 2 S demonstrated by. lung function tests. The diagnosis of occupational mesothelioma is based on meeting the following criteria: 1. Confirmed history of occupational exposure to asbestos. 2. Pathological evidence of mesothelioma. I 30 A-l. TOXICOLOGICAL REFERENCES Asbgs tos 1. Enterline, P . ; et. al.. A Study of the Pose-Rssoonss Relationship Asbestos Oust and Luna Cancer. Unpublished manuscript. 2. NIOSH. 1972. Criteria for a Recommended StandardOccuDaticnal Exoosu re to Asbestos. Cincinnati: 1 3. Murphy, R.L.U.; et al. 1971. N. Enq . J. Med. 285:1271. A. Pennsylvania Dept. of Pub! ic Health. Hnpubli shed Communicati on. 5. Selikoff, I.J.; et al. 1958. JAMA. 204:106. 6. Selikoff, I . C . : et al. Carbon Monoxide 1964. JAMA. 188:2?. 7. NIOSH. 1972. Criteria for a Recommended Star.dardOccuoaticr.al Exes sure to Carbon Monoxide. Cincinnati: NIOSH. 8. Sayers, R.R. ; at. al. 1929. USPHS Bull. 186. Washington: cpo. Q . - McFarland, n...A, 1944. J. Aviation Msd. 15:381. 10. Halpsrin, M.h . ; et al. 1959. J. Physiol. 146:583. 11. Horvath, S.M. 1972. `rch. Env. Health: 23:343. 12. Schulte, J.H. 1953. '-rch. Env. Health. 7:524 13. -Beard, R.R. ; and Wertreim, G; 1967. Am, 0. Pub. Health. 57 :2012. 14. Beard, R.R.,; and Grancstaff, N.W. 1970. Proc. Ann. Conf. Env. Toxic. 1 :^3. 15 . Trouton, D. ; anc Eysev/ck, H.J. 1961. Handbook of Abnormal Psycholr.cv. Lev/ York: Basic 5ooks. 16.'NIOSH. 1972. Criteria for a ?ecc~mgnded Standard Occ unattona T * tssure tn Caro on rcno.si ds . C i nc*nt\ =.z * : NIOSH. 65 Lead 17. 18. 19. 20. 21. 22. 23. Elkins, H. n. 1959. The Chemistry of Industrial Toxicology 2nd ed. 'lew York: John Wiley. Lane, ..E. 1949. 8rit. 1. ?nd. '<ed. 6:125. Williams, M.K.; et al. 1969. Brit. .1. Tnd. Med. 25:202. iilCSH. 1972. Criteria for a Recommended Standard Occupational Exposure to Inorganic Lead. Cincinnati: .`1I0SH. Hartocenesis, z Qcc. Hyg. 5:27^ and Zielhuis, R.L. 1962. Ann.. Dreeson, C .; et al. 1941. Public Health;. Bulletin 252. '-'ashington: -GPO. national Academy of Sciences, Division of Medical Sciences, Coirmittee on Biological Effects of Atmospheric Pollutants. 1971. Airborne Lead in ?**so ac tiye. No ise 24. NIO S H . 1972. Criteria for a Recommended Standard -- OccuDational Exposure to Noise. Cincinnati: NIQ5H. 25. Coles ; and Knight. 1960. Ann. noe. Hyq. 2:257. 25. vaffe; and Jones. 1961. U.S. Public Hea'th Service Publication 850. Washington: OPQ. 27. Schnei dsr: et al. 1951. H H A J. 22:245 PCJO Srohm; and Zlamal. 1962. Cas. Lek. Ces. 101:300. Czech. 29. Mancini-, and Stancari. 1962. Dass. Med. Ind. 31:239. Italian. 30. Chadwick. 1963. J . Larvncol. 77:467. 31. Filin. 1953. (loa. Tr. Prof. Tabol. 7:3 Russian. 32. ''estor.. 1963. J ., Aus. Inst. Aar. Sci . 29 :15. 33. Cohen; et al. 1970. Arch. Env. Health 20:514'. 3-. Turns; Jnd Robinson. 1970. Hearing sr.d Noise in Industry. London: Her Majesty's Stati entry Office. 35. Stone; et a l . 1971. MHA J . J 32:123 66 s Toluene Oiisocyantn 36. NIOSH. 1973. Criteria for a Recommended Standard Occupational Exposure ~o Toluene Diisocvana~s. Cincinnati : ;!0SH. 37. Walworth, i!.T. ; and Virchow, '/.E. 1959. AIHA J . 20:205. 38. Elkins, H.3.-, et al. 1962. AIHA J.'23.265. -39. Olass, 63:642._ and Thorn, N.G. 1954. -1.Z. -"ed. -J. 40. Williamson, K.S. 1964. Trans. Assoc. Ind. "ed.; n ff. 14:81,. 41. Maxon, F.C. 1964. Arch. Env. Health. 8:755. 42. Bruckner, H.C.; et al. 1968. Arch Env. Health. 16.619 43. Peters, J.M.; et al. 1968. Arch Env. Health. 16:642. 67 A-2. BIBLIOGRAPHY Asbestos ' 1. Arana, J.M. 1370. Poisoning, Toxicology, Symptoms, Treatments. Springfiela: Charles C. Thomas. 2. Council cn Occupational Health. 1963. Arch. Env. Health. 7:130. 3. Hamilton, A.; and Hardy, H.l. 1974. Industrial Toxicolocv. 3rd ed. Acton: Publishing Sciences Group. . 4. Morgan, W.K.C.; and Seaton, A. 1975. Occupational Lung Diseases. Philadelphia: W.8. Saunders. 5. Advisory Committee'on Asbestos Cancers. 1972. The Biological Effects of Asbestos. Delivered to './Grid Health Crganication ,Lyon, Oct. 5-6. 6. NIOSH. 1972. Criteria ^or a Recommended Standard Occupational Exposure-to Asbestos. Cincinnati: NIOSH' 7. Yater, W.M.; and Oliver, v.F. 1961. Symptom Diagnosis, 5th ed. New York: Appleton Century. Croft. Carbon Monoxide 1. NIOSH. 1973. Criteria for a Recommended Standard Occupational uxoosura to Carton Monoxide. Cincinnati: NIOSH. . 2. Gafafer, W.M. 1966. Occupational Diseases A Guide to their Recognition. Washington: II.S. Government Printing Office. . 3. Breaker, W . ; and Mossman, A.L. 1570. Toxic Gases: First Aid and Medical Treatment. Rutherford: Matheson Gas Prooucts. 4. Hunter, D. 1969. The Diseases of Occupations. 4th ed. Boston: Little, Brown. 5. Arena, *1.M .' 1970. Poisoninc, Toxicology, Svmotoms, Treatment. Sorinnfielo: Charles C. Thomas. 6. P l u n k e t t , 5.R. 1966. Handbook^ of Industri al Toxi col oqv. New York: Che1.:'.: cal - Pub l i s n i n g . 1 58 . SAMPLE RESETRATORY QUESTIONNAIRE Use the actual wording'of each question. Put X in the appropriate space after each question. When in doubt, record "N0.,: PREAMBLE: I am going to ask you some questions mainly about your cheat. I should like you to ' aosv e r 'Y E S 'or 'N O 1 whenever possible. YES NO N/A 1. Do y-ou u s u a l l y cough first..thing in the morning or on getting up? CCount a cough with first smoke or on first going out of doors. Exclude throat clearing or a single cough.) 2. Do ycu c o u g h like this on most days for as m uch as three months each year? 3. Do ycu cough at work? 4. Do yc-u u s u a l l y bring up some phlegm from your chest first thing in the nornihg or on getting up? ('Count p h l e g m with the on first going out of phlegm from the nose. phia.qm.) first smoke or doers. Exclude Count swallowed 1 91 c * 5. Do y o u bring up phlegm like this on most d a y s for as much as three months each year? 6. In the past three years, have you had a p e r i o d of (increased) cough and phlegm lasting 3 weeks or more? 7. Have you had more than one such period? S. Does y o u r chest ever feel tight or your breathing become difficult? . Du you get this apart from c:lds? (If YES: s p e c i f y . ..(Interviewer to code) (a) W i t h Exercise (b) At Work (c) Any Other Time If disabled from walking by skeletal or o t h e r physical disability put 'X' here. 10. Are 'ou troubled by shortness of breath, when hurrying on.the levels or walking up a slight.hill? (If 'NO* omit questions 11 and 12) 11. Do you get short of breath walking with other people of your own age on level ground? (If 'yo' omit question 12) 92 32 - Da ytiii b s v e I -o' sto p fo r breachvhen calk in g a t your pace ca le v e l ground? _ 33- .35o you 'usually h a v e a stuffy cose or `c a ta r r h a t t h e 'back o f your n o se in th e 14. So you have t h is In the s u a e :? _ 0 3 ''SO-' ~n been q u e s tio n s 13 and 14 , g o cro <ou-esticn Id) 35 - 25d yo u h a v e t h i s on nose c a y s fo r as nuea a s iis = u n r i s each. yuan? _ 2$_ Zhnnng z a s o a s t 3 years have you had any (r a e s t - m - ' a ; u h ic h has k e p t you o f f vork but f n a j i c : u s u a l a c t i v i t i e s f o r as ouch as a wsak? _ 17- you h n in ^ up to re palega than usual ns sty c f these illn esses? 2 3 - 2 s " s yn.o Iran roots than one i l l n e s s v i t h phls-pn l i k e t h i s in th e l a s t 3 years? Xi.V 'VpjL* aJOi .ryis.-Y^r.t stalls aft' .r each positive ansver.) 12.. jjr. ir.^vc-y irperarj cm affecting your cf U'-o-r-t 93 21 B ron ch itis? 22. Pneumonia? 23. Pleurisy? 24. Pulmonary Tuberculosis? 25. Bronchial Asthma? 26. Eczema? 27, Dermatitis? 28. Pneumoconiosis? 29. Byssinosis? '30. Other chest troubles? 31. Have you e v e r smoked? ________________ (Record 1i:o.' if subject has never smoked as m u c h as one cigarette a day, or 1 o z . tobacco a month, for as long as one year 94 32. Age when stopped_________ y e a rs. Was th is in the last nonth? If 'YES' to 31 and 32, fill in figures below: * Cigarettes/day - (Average including weekends) Oz. tobacco/week (handrolled) Cigars/week (large) Cigars/veek (snail) ___ ___ AMOUNT SMOKED BEFORE NOW___________ STOPPING ___ _________ ___ _________ ___ _________ ___ _________ OCCUPATION (1st Interview-Only) (Record on-lines the-years-in which subject has worked in any of these industries, e.g., 1960-1963) YES NO 33. Have you e v e r worked in a dusty job? __________________________ _ ____ _____ 34. In a coal n i n e ___________________ * _____ _____ 35. In any other nine? ______________ _____ _____ 36v In a cuarry? _______________ _____ ____ 37. In a foundry? __________________ _____ _____ 33. In a pottery? ___________________ _____ _____ 39. In a-cotton, flax or hemp mill? _____ ____ 40. With asbestos? 95 41. Ia any ocher duscy job? _________ If ' Y E S ', specify ________________ 42. Have you been exposed regularly Co r irricacing gas or chenical fumes? If 'YcS', give decails of nature and duration OCCUPATION (Follow-Up only) 43. What i s your present job? ___________________ 44. H o w long have you been doing it? _________ 45. What was your previous job in the factory? Taken with minor changes from Operating and Medical Codes of Fractice for Safa Working with Toulene Diisocyanate, Health Advisory C o m i c c e e , British Rubber Manufacturers' Association Ltd. j 96