Document dpnk5Y68EqweQ7kMJ5786jDR
FILE NAME Insurance Industry INS
DATE 1990
DOC INS072
DOCUMENT DESCRIPTION Book Excerpt - Medical Risks Trends in Mortality by Age & Time Elapsed - Study - Associated Disease Book Sponsored by Insurance Association
MEDICAL RISKS
Trends in Mortality by Age
and Time Elapsed
VOLUME 1
_
A Reference Volume Sponsored by
The Association of
Life Insurance
Medical Directors of America
and
The Society of Actuaries
Edward A. Lew A.M. F.S.A. Project Director and Editor
Jerzy Gajewski M.D. Ph.D.
Editor
Soc Arth Arth
47
Suite Sug
Ningule Ningule
Ningule kuad
Schaumburg IL 60173
PRAEGER
Westport Connecticut Connecticut
London
Library of Congress Publication Dala
Medical risks ; trends in mortality by age and time elapsed : a reference volume / sponsored by the Association of Life Insurance
Medical Directors of America and the Society of Actuaries ; Edward
A. Lew project director and editor ; Jerzy Gajewski editor
P.
cm
Includes indexes
ISBN 0-275-93786-0 sel : alk paper
ISBN 0-275-93787-9 vol 1 : alk paper
ISBN 0-275-93788-7 vol 2 : alk paper 1. Health status indicators Tables 2. Life
United Tables 3. Mortality States-
expectancy
Tables I. Lew Edward A. II Gajewski Jerzy III Association
of Life Insurance Medical Directors of America IV Society of
Actuaries
DNLM 1. Health Status Indicators 2. Life Expectancy United States 3. Mortality States WA 900 AA1
M48
RA407.3.M43 1990
614.4'273
DNLM
90-7707
British Library Cataloguing in Publication Data is available
Copyright '1990 by Praeger Publishers
All rights reserved No portion of this book may be reproduced by any process or technique without the
express written consent of the publisher
Library of Congress Catalog Card Number 90-7707
ISBN 0-275-93786-0 set 0-275-93787-9 vol )
0-275-93788-7 vol 2
664
664 664 664
First published in 1990
Praeger Publishers One Madison Avenue New York NY 10010 An imprint of Greenwood Publishing Group Inc.
Printed in the United States of America
ao ico
The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization Z39.48-1984
10987654321
SUBJECT INDEX continued
Aortic valve disease 6-42-43
Aortic valve transplantation 6-33 Aorto bypass surgery 6-54 Aorto disease surgical reconstruction for
at Baylor University 6-343 683A 683B 683C Aplastic anemia 14-4
mortality as associated with bone marrow transplantation for 14-36-37 1413A
phenylbutazone as cause of 3-23
Armed forces
occupational mortality
British 3-52 304A 402A 402B 402C U.S. 3-50 303A 4-56 406A 406B 406C
social class
British 3-52 304A
U.S. 3-50 53103A
Atherosclerosis 6-2 6-7 6-20 6-50 6-54-55
Athletes physical activity for former 3-29
Atrial fibrillation
as complication in thyroid disease 11-3
mortality as observed in 7-14 7-16 7-32 702A
703A 710A 710B
Atrial septal defect 6-30 6-32 Attention deficit disorder with hyperactivity 12-20 Australian Therapeutic Trial 7-94 Autosomal dominant muscular dystrophy 12-4 Autosomal recessive muscular dystrophy 12-4
AV block 7-1-2 7-14 7-16 7-19 27002A 703A
mortality as associated with use of pacemakers
with 7-60 720A Axis deviation 7-3 7-14 702A
Ararthryiatlhfmiibarillation 7-5 7-14 7-32 702A 710A 710B
ECG abnormalities 7-1-5 7-11 7-14 7-16 702A
703A
mortality as observed in Declined Lives 7-49 716A 716B 7611
Japanese
761
paroxysmal supraventricular tachycardia 7-5 premature contractions 7-4 7-28 7-30 708A
709A
rhythm and rate variations 7-14 702A sinus bradycardia 7-4 sinus tachycardia 7-4
ventricular conduction defects 7-14 702A Arterial occlusive disease 6-54-55 Arteriosclerosis as cause of death on death
certificate 2-3 Arteriovenous fistulas 6-55
Arthritis See specific arthritis Rheumatoid
O
B
Bacteremia 6-52 Bacterial endocarditis 6-30 6-34 6-42 6-47
mortality as observed in University of Mississippi
6-336 680A 680B
Bacteriuria 10-2
mortality as observed in the aged 10-20 1003A
1003B
Barlow's syndrome 6-42 Bayesian probability 1-5 endorphins release of and physical activity
3-30-31
Benign tumors mortality as observed in
Insured Lives London 5-209 540A
Insured Lives U.S. 5-203 537A
Bereavement as risk factor for mortality
3-25
arthritis
Arthritis syndrome association of jejunoileal bypass
surgery with 9-7
associated disease case study of 4-4-6
Asbestos exposure
effects on mortality 410A 410B 410C 410D 411A
411B 411C 411D 411E 411F 411G
as risk factor in cancer 5-1
Aspergillus clavatus 8-10 Aspirin effectiveness of in preventing recurrent
cerebral infarction 12-12
Asthma 8-6
follow studies on 8-6-7
life expectancy in 814A mortality as observed in 8-1 8-6
Insured Lives London 8-41 811A
Insured Lives U.S. 8-46 814A
Japanese Declined Lives 8-48 815A World War II veterans 8-45 813A
815B
815C
Bias 2-2
Bifascicular block 7-3
Biliary atresia and liver transplantation 9-4 Bipolar disorder 12-17-18 Bird fancier's lung 8-10
Shiley valve 6-43
Bladder extrophy of 10-4
Bladder cancer 5-2 5-6 5-7 5-8 5-9 5-10
cigarette smoking as contributory factor in 3-8 by ethnic groups 5-12 mortality as observed in
SEER Program 5-100-1 516A Seventh Day Adventists 306A
Blindness
diabetic retinopathy as leading cause of 11-2
legal definition of 14-55 mortality as associated with 1423A 1423B 1423C
and diabetes 14-55 1423B
mixture of two metals makes it difficult to evaluate the
For decades there was simply no place to
effect of one or the other Solvents not infrequently
mesothelioma of the malignant variety seen in the
established have similar neurotoxicity and mixtures of solvents
pleura and peritoneal cavity Even for well
oY
may lead to confusing observations
neoplasms inaccurate categorization exists and com
l
parisons among populations are often questionable "
Asbestos again provides a good example After the 10. Industry Is Constantly Changing with resulting a
first clinical case reports in the late 1920s Merewether
secular changes in industrial agents and processes
,
t
The was asked by the Factory Inspectorate in Great Britain
American Chemical Society has estimated that in 1984
\
70 i to investigate whether these cases were exceptions or
they were registering new chemicals at the rate of
i
pointed to a general problem Merewether shied away
per hour While the vast majority do not enter com- +
from the construction industry although most asbestos
merce at least several hundred do One can wonder :
was used there because many other exposures
how the brave new world envisaged in the Toxic Sub
cement silica wood dust etc. could have con-
stances Control Act will ever come into being since -!
founded the results Rather he observed workers in
preliminary laboratory investigation of potential hazard
asbestos textile factories where few other dusts
occurred Much disease was found subsequent focus
is most difficult and epidemiologic data take years to *-
accumulate
remained on asbestos workers in factories rather
than on much larger populations in industries where
asbestos products were used. ,,
In making quantitative projections for future esti- /
mates it must be appreciated that current occupational exposures are generally much different from those in
Pure exposures are the exception not the rule Concomitant or sequential multiple agent use is far
years past being less intense and better controlled Projections of future risk require great caution
more common because workers are employed in complex environments with multiple agent exposure Indeed not only are there multiple agents to be considered in the work environment but the personal envi-
ronment must also be taken into account as indicated
by the multiple factor interaction between asbestos and cigarette smoking benzene and radiation
11. Reproductive Effects
We know very little about intrauterine exposures
Thalidomide and diethylsilbesterol sensitized us to this possibility and experimental demonstration of transplacental angiosarcoma provided experimental data bearing on the matter Nevertheless as TuchmanDupleissis has ruefully commented laboratory screen-
8. A particular kind of multiple agent exposure is seen in the mobility of employment during a worker's
ing for adverse reproductive effects and birth defects has not lived up to the thalidomide promise
lifetime with opportunity for multiple sequential exposures to potential hazardous agents Unfortunately in most occupational studies lifetime occupational his-
tories have been the exception rather than the rule
although this is changing A few states require usual lifetime occupation to also be recorded on death certificates Even the description of last occupation on death certificates cannot speak for the variety of expo-
sures that could have occurred in a lifetime My files
contain a category for Director's Disease By the time an individual becomes a director of a corporation he or she has often passed from the shop floor to industrial management to corporate management and finally to the director's suite and has taken the effects of all
exposures with him
Case Study Associated Discase
associated cancer is now very much with
us and is involved in a multitude of public health industrial legal insurance and clinical management prob-
lems Yet these are due to an agent which was first
found to cause fatal pulmonary fibrosis in 1899 in which parenchymal and pleural fibrosis was known to be common in the 1930s and where lung cancer was seen in 1935.1 Additionally a classic cohort study produced reliable epidemiologic evidence in 1955.1s
Doll studied the mortality experience of 113 men
who worked for a least 20 years in a scheduled area
in an asbestos products factory during 1922-53 Some 0.8 deaths of lung cancer were anticipated and 11 were
seen He stated that From the data it can be con-
9. Diagnostic and Categorization Uncertainties
cluded that lung cancer was a specific industrial hazard of certain asbestos workers among men employed
is often difficult to fit new diseases into the pre-
for 20 or more years This conclusion was entirely
viously established rigid categories of the International
accurate Yet when it is examined closely one can
Classification of Diseases This is true for the 6th to 8th
appreciate how the constraints enumerated above lim-
revisions and unfortunately in the current 9th revision
ited the full characterization of the problem that could
as well
have warned of what lay ahead
4-4
shorter than 20 years than are exposed for the longer
investigated lung cancer Yet in retrospect
term
Doll one
not expect that the pan-
him the
could with hindsight associated
neoplasms
meso-
of other
cancer pharyngeal and
Finally Doll did not have available to smoking histories of the men he studied and he was
only Irointestinal could have been seen unable to investigate the multiple factor interaction
renal cancer
Belioma cancer of 39 deaths among 113 people
between asbestos exposure and cigarette smoking "
consider since this infor-
in a study excessive for example was not well established
He was also unable to even
made available to
Ge
Mesothelioma did have one case of respiratory can-
mation was not included in the data
wok oO
until 1960. Doll endothelioma of the pleura but
him what might be the effect of asbestos brought
categorized as
warrant further special
home on workers clothes Newhouse and Thompson
__
cer single case was insufficient to
Too other neo-
did not publish their study of mesothelioma among
notice ,
a
A single case is a weak signal
4
of asbestos workers until 1965,21 and
notice
in some excess 2.3 expected
plasm were present
could
family contacts
data in
et al did not provide quantitative
But with such limited experience one
Anderson
observed
whether or not significant excess
this regard until 1976.
hope to evaawlauiatteed a much larger cohort study In
Considering the foregoing it is sobering to realize
existed This
based on 166,853 years of
if asbestos had first been introduced in 1945 and
one
for
example deaths were analyzed Table 4-2
2,271
that
Doll had investigated the experiences of workers in a
observation of this new industry in 1975 or 1980 we might
careful He knew that changes in
to an Doll was very
and in conditions
plant
be
equally excellent study establish-
now
pointing
risk
of
workers
heavily
exposed
in
Hens industry in production techniques the 1930s on ing lung cancer as a
would know little or
do exposure had occured from
a manufacturing plant But we
potential of
he understood that he could only write
nothing about the full spectrum of asbestos neoplastic
Seats Therefore
Moreover exposure measurements
risk the very large number of people who have been
Seer
about the pasmtade The only population available to
in the use of the product the augmentation of
gm
had not beenwere the men working in the scheduled
exposed
that risk
by
concomitant
cigarette
smoking
the
him for study
as having heaviest
of bystander exposure in shipyards and the
pt
government area
and he could not provide information on
problem
construction
industry
and
we
might
conclude
that
exposures would happen to people who were associated
asbestos accounted for very little of the cancer burden
ESPN what
We now know that later intense exposure
in the United States Indeed Doll would not have been
with less in the same plant were unfortunately also
able to make the estimate that % of all lung cancer in
exposures associated with risk.18
the United States was due to asbestos exposure.23
this review it is useful to report the
Doll stated only what he knew The workers whose
To complete status of occupational disease derived from
had been studied were employed in an
during experiences
Doll had no
current
asbestos exposure
the period 1940 to 1979. This
manufacturing factory asbestos products
was studied by W. J. Nicholson and his colleagues,, ,,
way of knowing that other exposed workers
who investigated employment and asbestos exposure
not studied by him also had such risk however they
asbestos industries mining and mill-
did Unfortunately it turned out that for each worker
in important manufacture of asbestos products sec-
manufacturing asbestos products over a hundred were
ing
primary manufacturing
shipbuilding
and
ship
repair
with their use Doll could thus not tell us
ondary
the construction industry railroad
eaxbopuotsesdhipyard workers brake repair workers family
insulation work
locomotives utility services sta-
construction workers and those exposed as
engine repair steaamnd firemen chemical plants and
contactsof environmental circumstances Doll spoke of
tionary engineers
maintenance and merchant
a result
This was the result of
refineries automobile
27.5
personnel exposure of 20 or more years
the labour in searching
marine engine room
Approximately
the
a practical consideration " ... ...
million new entrants joined these industries during
out the individual records of men employed for shorter
32 had lesser intensity of exposure and
periods would be disproportionately great ... ... " Thus
of workers with shorter
period Some
into account such
had greater intensity Taking
68
in each of the
data concerning experiences
followed for
factors as likely duration of employment
- 1 month 1 year 10 years -
exposures
of duration from onset of such
trades dose intensity x time was considered It was
calculated that there were approximately 5,000 asbes-
equally lownegrpeeruniaovdasilable to him Yet we now know
deaths in 1982 and that this
exposure
be associated with a
that such shorter exposure may
related lung cancer number would remain very much the same until the
very substantial risk For asbestos as for many agents
2000. For all associated cancer in these
more workers are exposed for periods
year
very many
4-5
occupations and industries 1982 a saw little over 8,000
deaths it was projected that this would rise to nearly
10,000 by 1987 and then gradually decline over the
next 20 years provided there was no further asbestos exposure after 1980. These estimates did not include
deaths of associated cancer other than in the
selected occupations and industries since data were
inadequate for such evaluations Nor did they include deaths from asbestosis nor disability from nonfatal
asbestotic pulmonary and pleural changes
Populations at Risk
The foregoing has been devoted primarily to cal-
culations of deaths from asbestos We are on much less
firm ground concerning workers who have been exposed and may have the disease but are not
expected to suffer death Of the 27.5 million individuals
who through 1979 had potential asbestos exposure at
their work in the trades mentioned 18.8 million had exposure in excess of the equivalent of two months
employment as an insulator or asbestos factory worker
Some 21 million of the 27.5 million and 14.1 million of the 18.8 million were estimated to have been alive on
January 1 1980. These figures are given for those who reflect upon approaches to medical surveillance
Costs of Associated Disease and Death
W. G. Johnson and E. Heler have provided calculations concerning the losses borne by workers or other
survivors as a result of death and disability from exposure to asbestos They concluded that deaths between 1979 and 2027 would cost 309 billion in addition to costs of medical care litigation costs and administrative costs incurred by social agencies which
costs were not included in the estimates If to these amounts are added losses between 1967 and 1979 a total well in excess of 326 billion is reached Paren-
thetically pain and suffering of the workers and their families were considered not measurable Disability compensation costs were also omitted although such expenditures are expected to reach sums of many bil-
lions of dollars
Calculations similar to the above have not been attempted for other occupational hazards
Case Study New York State
A different sort of analysis of the extent of occupational disease was recently undertaken for New York State using estimates that occupational exposures cause approximately 100,000 deaths and 400,000 new cases of acute and chronic disease annually in the
United States and that an estimated 2 million workers i
in the country are severely or partially disabled
a6
occupational illnesses Assuming that New York SftatreSotamte
generally suffers approximately tenth of all
occu-
pational diseases in the country it was calculated that #
occupational exposures are responsible each year in |
New York State for 40,000 new cases of
diseases and 10,000 disease occupational
deaths with an 2a
additional 200,000 workers in the state suffering from 4
term disability due to occupational illness
cautiously These estimates admittedly crude were made
because there existed no comprehensive mechanisms either nationally or in New York State for the systematic
collection of data on disease disability or death resulting from occupational causes It was observed that It is quite possible in fact that the t above figures underestimate substantially the full
extent of the problem since worker's compensation
systems identified fewer than % of illnesses of occu-
pational origin and that the data collection systems mandated by the Occupational Safety and Health
Administration identify fewer than % of occupational illnesses It may also be noted that the Congressional
Office of Technology Assessment recently concluded
that with so little agreement about the number of
occupational illnesses it refused to take a position
about the correct number
Reviewing New York State industry in addition to associated disease a litany of occupational illnesses was listed cancer of the bladder in dye workers
leukemia with benzene exposure occupational bronchitis disorders of the nervous system with solvent
exposure renal disease with lead dementia and
premature senility following chronic exposure to
neurotoxins heart disease in workers exposed to nitro-
glycerin and carbon monoxide reproductive impair- 2
a ment with lead and variety of pesticides chronic oh
repetitive trauma yielding diseases of the musculoskel- Soh
WED etal system induced hearing loss and skin can-
cer in workers exposed to coal tar pitch
et NLL
Insurance Experience ADDDower
BA S Mortality experience among men and women
insured under group life insurance provides data for
RPURTHOE judging differences in mortality among actively
employed persons by industrial groupings The 1970- SR 79 experience indicated that the following industries recorded mortality at least 15 higher than the aver- AR
age for all industries combined
eee.
er
INSULATION WORKERS
U.S. AND CANADA 410
References and Acknowledgments
1. I. J. Selikoff E. C. Hammond and H. Seidman Mortality Experience of Insulation Workers in the United States and Canada 1943-76 Ann N.Y. Acad Sci 330 1979 91-116
2. I. J. Selikoff E. C. Hammond and H. Seidman Latency of Asbestos Disease Among Insulation Workers in the United States and Canada Cancer
46 No. 12 1980 2736-40
Subjects Studied
1 632 members of two locals of the International
Association of Heat and Frost Insulators and Asbestos
Workers the insulators union in the New York - New
Jersey metropolitan area who were registered January
1 1943 as well as 833 members of these locals who
joined the insulators union during the period January 1 1943 to December 31 1962 and had no prior asbestos employment before entering the union Each group was studied separately
On January 1 1943 about half of the 632 members had been exposed to asbestos for 20 years or longer
almost all had had 10 or more years of exposure
2 17,800 men on the rolls of the insulators union in the United States and Canada on January 1 1967
Follow In the first study 632 subjects were traced
from January 1 1943 to December 31 1962 and then further from December 31 1962 to December 31 1976. The 833 subjects were traced from the date of joining the union to December 31 1976
In the second study the 17,800 workers were
traced from January 1 1967 to December 31 1976
Clinical data histological findings on surgery or autopsy and roentgenograms as well as information
given on death certificates were used to determine
causes of death
Limitations of Studies Information on smoking habits was not available The experience for the most part covered a prolonged period of time during which many changes occurred in the handling of asbestos
Mortality Results and Conclusions Expected deaths for the two groups in the first study 632 and 833 subjects were calculated on the basis of white male agespecific U.S. death rates for 1949-76 death rates for specific causes of death during 1943-48 were extrapolated from figures for 1949-76
Expected deaths for the 17,800 subjects in the second study were calculated on the basis of white male specific U.S. death rates for 1967-76
Study 1 An analysis of the mortality by years of exposure to Bt
asbestos based on the experience among 632 New York and New Jersey asbestos insulation workers who $4 had been working in the industry prior to January 1 1943 and who were traced over the period January 1 1943 through December 31 1976 showed
a Only 9 deaths among workers with less than 20
years of exposure to asbestos or about the same as the
number of expected deaths
b 119 deaths among workers with 20-34 years of exposure to asbestos resulting in a mortality ratio of
about 150 for all causes of death There were 53
deaths from all forms of cancer with a mortality ratio of nearly 400 and 26 deaths from lung cancer with a mortality ratio of almost 900 There were 7 deaths
from mesothelioma and 3 deaths from asbestosis
among these workers
c 350 deaths among workers with 35 or more
years of exposure to asbestos resulting in a mortality
ratio of about 150 for all causes of death There were
155 deaths from all forms of cancer and a mortality ratio of about 370 and 67 deaths from lung cancer with a mortality ratio of about 700 There were 31 deaths
from mesothelioma and 38 from asbestosis among
these workers
EM
ape Clearly mesothelioma and asbestosis occurred
only after a long period of time had elapsed following et
exposure to asbestos
An analysis of the mortality by years of exposure to asbestos based on the experience of 833 New York and New Jersey asbestos workers who began working after January 1 1943 and were traced over the period
e from beginning of work to December 31 1976
showed Sener
a Only 23 deaths among workers with less than
eae 20 years of exposure to asbestos or only about 60 of
the expected deaths a b 39 deaths among workers with 20-34 years of Oe
exposure to asbestos resulting in a mortality ratio of
about 160 for all causes of death There were 15
deaths from all forms of cancer and a mortality ratio of
about 300 There were 3 deaths from mesothelioma and 6 deaths from asbestosis among these workers
Study 2
An analysis of the mortality by years of exposure to asbestos based on the experience of some 17,800 U.S. and Canadian asbestos workers over the period Janu-
ary 1 1967 to December 31 1976 showed
workers with less than 20
a 325
deaths
among asbestos
resulting
in
a
mortality
exposure to
of
for all causes of death There were 83
exposure of 115
of cancer with a mortality ratio of
from all forms
:
deaths
and 36 deaths from lung cancer with a
from about 200
of 300 There were 5 deaths from mes-
ratio8 from asbestosis and 8 from infec-
othelloma mortality othelloma
disease
disease
among
these these
workers
pulmonary
py
workers with deaths among
20 or more
1,946
to asbestos resulting in a mortality
yearsyears 912 : of e1x4po1sufrore all causes of death There were of
mortality ratio
of
all forms of cancer with
from
ratio
329 deaths and 450 deaths from lung cancer with a mortal-
329 Hyratio rex. % of 480 There were also 204 deaths from non-
disease with a mortality ratio of
fa Infectious pulmonary * In addition there were 170 deaths from meso-
.
379% thelloma
and 160 deaths from asbestosis
These findings confirm strongly the conclusion that very high mortality from mesothelioma asbestosis and infectious pulmonary disease occurs among asbestos workers after a long period of time 20 or more
years have elapsed following exposure to asbestos
c Further analysis of lung cancer and mesothelioma mortality among the 17,800 asbestos insulation workers by time elapsed since beginning of employment including asbestos indicates that ) lung cancer began to appear after about 10 years had elapsed the
mortality ratio from this cause rose to about 600 after
30-39 years from beginning of employment in the insulation industry thereafter mortality ratios declined somewhat and ii mesothelioma began to appear after
15 years had elapsed the death rate from this cause rose steadily to more than 6 per 1000 after 35-44 years and to more than 8 per 1000 after 45 years from begin-
ning of employment in the insulation industry
4-73
INSULATION WORKERS - U.S. AND CANADA
TABLE 410A ANALYSIS OF MORTALITY BY CAUSE ACCORDING TO DURATION OF EXPOSURE TO ASBESTOS
632 NY ASBESTOS INSULATION WORKERS JAN 1 1943 - DEC 31 1976
Cause of Death
LESS THAN 20 YEARS
EXPOSURE TO ASBESTOS
Deaths Mortality
Observed Expected Ratio
d
d 100
20-34 YEARS EXPOSURE TO ASBESTOS
Deaths
Observed Expected
d
d
Mortality
Ratio
100
35 OR MORE YEARS EXPOSURE TO ASBESTOS
Deaths Mortality
Observed Expected Ratio
d
d 100
TOTAL
Deaths
Observed Expected
d
d
Mortality
Ratio
100
All Causes
9
All Forms of Cancer
OON
Cancer of Lung
OON
Mesothelioma
OON
Cancer of Esophagus Stomach
Colon and Rectum
ON
All Other Cancer
ON
Infectious Pulmonary Disease O
Asbestosis
on
All Other Causes
on
9.0
100
119
80.4
148
350 239.5 146
478
328.9
145
1.1
182
53
13.5
393
155
42.4
366
210
57,0
368
0.2
0
NA
NA
26
3.0
867
7
NA
NA
67
10.1
663
13
NA
NA
93
13.3
699
38
NA
NA
0.03
0
0.6
333
0.1
0
NA
NA
7.8
90
13
3.8
342
7
6.7
104
4
1.6
250
3
NA
NA
62
65.3
95
8248
11.0
273
8248
21.3
127
8248
7.6
605
8248
NA
NA
154
189.5
81
32772
15.1
285
32772
28.6
126
32772
9.3
484
32772
NA
NA
223
262.6
85
* Expected deaths calculated on white male specific U.S. death rates for 1949-76 NA Rare cause of death in general population expected death rates not available Source Reference 1 Table 4 reproduced with permission of authors and publisher New York Academy of Sciences
ANALYSIS OF MORTALITY BY CAUSE ACCORDING TO DURATION OFEXPOSURE TO ASBESTOS
833 NY ASBESTOS WORKERS JAN 1 1943 D~EC 31 1976
Cause of Death
LESS THAN 20 YEARS EXPOSURE TO ASBESTOS
Deaths Mortality
Observed Expected Ratio
d
d 100
20-34 YEARS
EXPOSURE TO ASBESTOS
Deaths Mortality
Observed Expected 100 Ratio
d
d
100
TOTAL
Deaths
Observed Expected
d
d
Mortality
Ratio
100
All Causes
3520-2000
All Forms of Cancer
3520-20
Cancer of Lung
3520-200
Mesothelioma
3520-200
Cancer of Esophagus Stomach Colon and Rectum 3520-20
All Other Cancer
3520-200
Infectious Pulmonary Disease
3520-200
Asbestosis
3520-200
All Other Causes
18
39.8
58
39
5.1
98
15
1.1
182
8
NA
NA
3
0.7
143
2
3.3
61
2
0.5
0
7
NA
NA
6
34.2
53
17
24.8
157
228
5.0
300
228
1.8
444
10
NA
NA
3
0.8
250
34 6
2.4
83
3446
0.6
1,167
7
NA
NA
3446
19.2
89
35
64.6
96
10.1
198
2.9
345
NA
NA
1.5
200
5.7
70
1.1
636
NA
NA
53.4
66
Expected
deaths
calculated
on
white
male
specific
U.S.
death
rates
for
1949-76
NA - Rare cause of death in general population expected death rates not available
Source Reference 1 Table 6 reproduced with permission of authors and publisher New York Academy of Sciences
4-75
INSULATION WORKERS M U.S. AND CANADA
TABLE 410C
ANALYSIS OF MORTALITY BY CAUSE ACCORDING TO DURATION OF EXPOSURE SINCE EMPLOYMENT 17,800 U.S. AND CANADIAN ASBESTOS WORKERS JAN 1 1967 - DEC 31 1976
at
Cause of Death
LESS THAN 20 YEARS
EXPOSURE TO ASBESTOS
Deaths Mortality
Observed Expected Ratio
d
d
100
20-34 YEARS
EXPOSURE TO ASBESTOS
Deaths
Observed Expected
d
d
Mortality
Ratio
100
TOTAL
Deaths
Observed Expected
d
d
Mortality
Ratio
100
All Causes
325
All Forms of Cancer
83
Cancer of Lung
36
Mesothelioma 5
Cancer of Esophagus Stomach Colon and Rectum 6
All Other Cancer
36
Infectious Pulmonary Disease
8
Asbestosis 8
All Other Causes
234
282.9 42.6 11.9
NA 6.2 24.5 5.2 NA
235.1
115 195 303 NA
97 147
154 NA
100
1,946
912 450 170
93 199
204 160
830
1,376.0
277.1
93.7 NA 53.2 130.2
53.8 NA
1,045.1
141 329 480 NA 175 153 379 NA
79
2,271
995 486 175
99 235 212 168
1,064
1,658.9
319.7 105.6
NA 59.4 154.7
59.0 NA
1,280.2
137 311 460 NA 167 152 359 NA
83
* Expected deaths calculated on white male specific U.S. death rates for 1967-76 NA Rare cause of death in general population expected death rates not available * Number of observed deaths based on best evidence including autopsy surgical and clinical findings Source Reference 1 Table 16 reproduced with permission of authors and publisher New York Academy of Sciences
4-76
INSULATION WORKERS U.S. AND CANADA
TABLE 410D
OF MORTALITY FROM LUNG CANCER AND MESOTHELIOMA
EMPLOYMENT
ANALYSIS
TO DURATION DURATION OF EXPOSURE SINCE
ACCORDING
1967
DEC 31 1976
U.S. AND CANADIAN ASBESTOS WORKERS JAN 1
17,800
Employment | Lung Cancer
Mesothelioma
ee
of
Mortality
Observed Death Rate
Duration
Since
Number
Deaths Observedt E_xpected
Ratio
Deaths
per 1000
}
Exposure
of Men
Exposure
d
100
d
1000
i
Ages
Employment
fi
E
d
0
0.7
%
0 42 3 27
Less 10 Years
8,190
26,393
7
2.7
255
0 42 3 27
than
9,063 29,003 29 8.5 340 042327
10-14
9,948
34,066
348
0 42 3 27
A
59
17.0
15-19
8,887
31,268
500
004223327
tes 20-24
105
21.0
6,596
20,657
18.4
608
004223327
B25e-29
3,547
11,598
112
568
004223327
3b 30-34
65
11.5
5,403
493
004223327
2,020
8.1
Fe 35-39
1,108
3,160
40
389 .
004223327
40-44 at
1,448
5,305
69
17.8
aR... 45 and Longer
U.S. death rates for 1967-76
: Expected deaths calculated on white male specific
surgical and clinical findings
Expected a
based on best evidence evidence including autopsy
of Sciences
York Academy
* N umber of observed deaths deaths
of authors and publisher New
Table 17 17 reproduced with permission
4
Reference 1
Source
Source
0.0 0.0 0.15 0.29 1.55 2.76 6.29 6.33
8.11
4-77
ASBESTOS AND SMOKING 411
References and Acknowledgments
1. E. C. Hammond 1. J. Selikoff and H. Seidman Asbestos Exposure Cigarette Smoking and Death . des Ann N.Y. Acad Sci 330 1979 473-90 . J. Selikoff H. Seidman and E. C. Hammond Mortality Effects of Cigarette Smoking Among Amosite Factory Workers JNCI 65 1980 507-13
3. H. Seidman and I. J. Selikoff Asbestos Exposure
Cigarette Smoking and Life Expectancy Abstract Proceedings of the International Symposium on the Prevention of Occupational Cancer Helsinki 21-24 April 1981. Occupational Safety and Health Series No. 46 p 177 International Labor Office
Geneva
Subjects Studied
1 17,800 members of the International Association of Heat and Frost Insulators and Asbestos Workers
alive on January 1 1967 representing approximately
120 local unions in various parts of the United States
and Canada including Alaska and Hawaii some 12,683
had fewer than 20 years of exposure to asbestos and 12,051 had 20 years or more of exposure The average age of the former was 36.3 and of the latter 53.8 with
an average age of 44.4 for all of the subjects In 1966 union members were asked to complete a questionnaire on smoking habits and use of protective masks
The control group was selected from the American
Cancer Society's Cancer Prevention Study launched in the fall of 1959. They comprised 73,763 white men who were not farmers had no more than a high school education had a history of occupational exposure to dust fumes vapors gases chemicals or radiation and were alive January 1 1967. They were classified according to their smoking habits specific death rates for each smoking classification were computed
2 582 amosite asbestos factory workers who worked from June 1941 through December 1945 and were alive 20 years after beginning of employment
during 1961-65 Most of these men had a history of
smoking
3 Same as in reference 1 - 17,800 members of the asbestos insulators union of whom 10,101 were under age 40 on January 1 1967. Some 9,591 had a his-
tory of cigarette smoking at entry and 1,457 had never smoked regularly
Follow
1 Subjects traced from January 1 1967 to
December 31 1976
2 Subjects traced from date they had 20 years of exposure to asbestos during 1961-65 to December 31
1977
3 Subjects traced from January 1 1967 to January
1 1980
January
Limitations of Studies
1 The experience extended over a long period of time during which considerable change occurred in the handling of asbestos and in the smoking habits of the population for instance reduced tar and nicotine content of cigarettes during the 1970s Subjects and controls may have modified their smoking habits differently over the years
2 The factory in which the subjects worked was closed in 1954 so that for most of the subjects there was no further occupational exposure to asbestos
thereafter
3 Same as for reference 1
Mortality Results and Conclusions Expected deaths in study 1 were calculated on the basis of specific
death rates among the controls ~ men with the characteristics indicated selected from the American Can-
cer Society's Cancer Prevention Study classified according to smoking habits
Expected deaths in study 2 were calculated 1 on the basis of specific death rates among New Jersey
white males 1963-66 1967-71 and 1972-77 without
regard to smoking habits and 2 on the basis of ageand smoking death rates developed in the American Cancer Society's study for the controls selected in study 1
Expected deaths in study 3 were calculated on the basis of age- and smoking death rates in the American Cancer Society's study extrapolated to Janu-
ary 1 1980
Causes of death in studies 1 and 2 were based on
death certificates for the controls but also on clinical and pathological reports for the subjects exposed to asbestos This had to be done to identify the deaths
attributable to mesothelioma and asbestosis
1 The first study showed that irrespective of smoking habits the men who had been exposed to asbestos dust for a least 20 years experienced mortality
from all causes of about 170 of that in the control
group their relative mortality from cancer was about 350 and from infectious pulmonary diseases about 300 Their relative lung cancer death rate was
about 550 and their relative death rate from cancer
of the larynx was about 360
There were 170 deaths 8.7 from mesothelioma and 160 deaths from asbestosis 8.2 based on the best available evidence
arent ratio
who who of 1 non
the who
mo
cig- The asbestos asbestos workers who smoked 20 or more
showed an overall all causes mortality The
a day showed 200 in relation to asbestos workers
about
ratio
smoked their relative mortality from cancer
never who
the
lung
was
over
1,000
of
that
among
nonsmokers a), Compared
:
to the lung cancer death rates among controls who never smoked the asbestos workers
20 or more cigarettes a day recorded a
controls smoked 5
mortality mortality
mortality
whomortality asbestos (
Years ae about about
8,700 ratio of about
The study of amosite asbestos factory workers
been exposed to
dust for at least 20
Indicated relative mortality from all causes of
death 190 in relation to New Jersey
rates but
about 220 in relation to the mortality ratios in the
: control group Their relative mortality from cancer was
bout 350 in relation to New Jersey cancer death
bout
and about 390 in relation to the cancer death
rates the control group their relative mortality ratios
from lung cancer was about 600 in relation to both
New Jersey and control group death rates from this
cause There were 14 deaths from mesothelioma
4.7 and 18 deaths from asbestosis % among
them
In relation to smoking habits the amosite asbestos workers with a history of cigarette smoking recorded an overall all causes mortality ratio of about 210 compared to men with a matching history of smoking in the American Cancer Society's study but a mortality
ratio of about 375 in relation to nonsmokers The
corresponding figures for lung cancer were about 600 and 8,000 respectively
3 This study of insulation workers showed that workers with a history of cigarette smoking experi-
enced a relative mortality about 150 in relation to
controls with similar smoking histories in the broad age range up to 80. Compared to controls who never smoked the relative mortality was about 250 over a period of at least 40 years from the start of work with
asbestos
The study demonstrated clearly that cigarette smoking greatly increased the mortality of asbestos workers over a prolonged period
ASBESTOS AND SMOKING
TABLE 411A
ANALYSIS OF MORTALITY BY CAUSE EXPERIENCE 20 YEARS OR LONGER AFTER FIRST OCCUPATIONAL EXPOSURE TO ASBESTOS DUST
Cause
Deaths
Observed
E_ xpected
d
d
Mortality
Ratio
100
All Causes
1,946
1,148
170
Cancer Cardiovascular
Infectious Pulmonary Disease
Asbestosis All Other Causes
912 566 204 160 264
259 660 NA NA 161
352 86
NA NA 164
Lung Cancer
Mesothelioma
450 170
82 NA
51 NA
Rectum
55
31
181
i
Pancreas
21
16
131
i
Larynx Buccal Cavity and Pharynx
27
8
360
Stomach
21
13
168
Prostate
26
18
142
*
Expected deaths based on experience of control group * Number of observed deaths based on best evidence including autopsy surgical and
clinical findings
NA Rare cause of death in general population expected death rates not available Source Reference 1 Table 2 reproduced with permission of authors and publishers New
York Academy of Sciences
4-79
ASBESTOS AND SMOKING
TABLE 411B ANALYSIS OF MORTALTY - TOTAL AND LUNG CANCER BY SMOKING HABITS EXPERIENCE 20 YEARS OR LONGER AFTER FIRST OCCUPATIONAL EXPOSURE TO ASBESTOS DUST
Smoking Habits
Current
Ex Less Than 5 Years Ex 5 to 9 Years Ex 10 Years Plus
Observed
Deaths
ALL CAUSES OF DEATH
Expected Deaths
To All
To Men
Asbestos
Workers
=Who Never
Smoked
Mortality Ratio
To All
To Men
Asbestos Never
Workers Smoked
Observed
Deaths
LUNG CANCER
Expected Deaths
To All
To Men
Asbestos Who Never
Workers Smoked
Mortality Ratio
To All
To Men
estos Who Never
Workers Smoked
20 OR MORE CIGARETTES PER DAY
565
481.3
285.4
117
198
171
116.8
16.4
166
137.5
81.8
121
203
201
33.3
4.7
61
69.6
41.2
712
136.5
81.2
88
148
82
138
201
17.1
2.4
201
31.4
4.4
146 162
58
48
1,040 1,151 415
339
Current
Ex Less Than 5 Years
Ex 5 to 9 Years Ex 10 Years Plus
143
127.6
22
20.0
10
11.5
31
43.6
Pipe and Cigars Only
Never Smoked Regularly
86
112.5
94
158.2
Total including unknown
1,946
1,946.0
smoking habits
LESS THAN 20 CIGARETTES PER DAY
75.7 11.9
6.8 25.8
66.7
158.0
1,158.3
112
189
105
110
185
105
87
146
1
71
120
5
76
129
3
59
100
5
100
168
450
29.5 4.8 2.5 9.8 24.2 35.5
450.0
* Expected deaths based on experience of control group * Where the number of deaths is 5 to 14 the mortality ratio is enclosed in parentheses A dash - indicates fewer than 5 deaths
** Number of observed deaths based on best evidence including autopsy surgical and clinical findings
Source Reference 1 Table 6A reproduced with permission of authors and publisher New York Academy of Sciences
4.2
129
915
0.7
104
740
0.35
-
-
1.4
51
362
3.0
-
-
5.0
14
100
63.4
100
710
4-80
es
a
ASBESTOS AND SMOKING
TABLE 411C
ANALYSIS OF LUNG CANCER MORTALITY BY SMOKING HABITS EXPERIENCE 20 YEARS OR LONGER AFTER FIRST OCCUPATIONAL EXPOSURE TO ASBESTOS DUST
Smoking Habits
Deaths
Observed d
= Expected
d
Mortality
Ratio
100
Total With Known Smoking Habits
History of Cigarettes Current 20 or More Cigarettes Per Day Current Less Than 20 Cigarettes Per Day
Ex Cigarettes
Pipe and Cigars Only
Never Smoked Regularly
276 268 152
31 83
4 4
6.0 4.7 1.7 0.6 2.3 0.6 0.7
4,623 5,763 8,736 5,082 3,656
702
533
* Expected deaths based on experience of control group Reference 1 Table 7A reproduced with permission of authors and publisher New York
Source
Academy of Sciences
ASBESTOS AND SMOKING
TABLE 411D
ANALYSIS OF MORTALITY BY CAUSE EXPERIENCE 20 YEARS OR LONGER AFTER FIRST OCCUPATIONAL EXPOSURE TO ASBESTOS DUST
Cause
All Causes Cancer All Sites
Cancer
Lung
Mesothelioma
Larynx Oral Cavity and Pharynx
Rectum
Infectious Pulmonary Disease
Asbestosis
Cardiovascular Diseases
Observed
Deaths
304 116
Expected Deaths
Based On NJ Death
Rates
Based On ACS Death
Rates
158.6 33.4
137.1 29.8
60 14
5 11
24 18
122
10.1 NA 1.6 5.2
4.7 NA
95.3
10.1 NA 1.0 3.7
7.4 NA
81.2
According to best evidence available
NA rare disease in general population expected death rates not available
Source Reference 2 Table 4 reproduced with permission of authors
Mortality Ratios
Based On NJ Death
Rates
Based On ACS Death
Rates
192 347
222 389
594 NA 313
212
511 NA
128
594 NA 500 297
324 NA
150
4-81
ASBESTOS AND SMOKING
TABLE 411E
OF ALL CAUSES MORTALITY BY SMOKING HABITS
ANALYSIS
OCCUPATIONAL EXPOSURE TO ASBESTOS DUST
EXPERIENCE 20 YEARS OR LONGER AFTER FIRST
Smoking Habits
Observed
Deaths
Expected Deaths
Based On Men
Based On Men
With Matching
Who Never
History of
Smoked
Smoking Regularly
History of Cigarette Smoking
Never Smoked Regularly
Pipe or Cigars Only Smoking History Unknown
Total
214 38 41 11
304
102.3 15.5 18.1 1.2
137.1
56.7 15.5 17.7
0.8
90.7
Source Reference 2 Table 6 reproduced with permission of authors
Mortality Ratios
Based On Men _
With Matching History of
Smoking
_Based OnMen
Who Never Smoked
Regularly
209 245 227 917
222
377 245 232
1,375
336
ASBESTOS AND SMOKING TABLE 411F
ANALYSIS OF LUNG CANCER MORTALITY BY SMOEKXIPNOGSUHRAEBITTOS ASBESTOS DUST EXPERIENCE 20 YEARS OR LONGER AFTER FIRST OCCUPATIONAL
Smoking Habits
History of Cigarette Smoking Never Smoked Regularly Pipe or Cigars Only Smoking History Unknown
Total
Observed Deaths Lung
Cancert
55 3 2 0
60
Expected
Based On Men
With
History of
Smoking
Deaths Based On Men Who Never Smoked
Regularly
9.6 0.2 0.2 0.1
10.1
0.7 0.2 0.2 0.0
1.1
According to best evidence available
Source Reference 2 Table 7 reproduced with permission of authors
Mortality Ratios
Based On Men
With
History of
Smoking
Based On Men Who Never Smoked
Regularly
573
1,500
~
1,000
0
594
7,858 1,500 1,000
0
5,455
4-82
ASBESTOS AND SMOKING
TABLE 411G BY AGE AT START OF WORK WITH ASBESTOS
ANALYSIS OF MORTALITY HABITS AND TIME ELAPSED
BY SMOKING
Years Elapsed
Start
From
>
10 SU28NE SU28NE SU28NE SU28NE SU28NE
02348 02348 02348 02348 50
0289 0289 0289 0289
Proportion Dead
Insulation
Insulation Workers
Never Insulation History of
Smoked Cigarette
Regularly Smoking
Controls
Never
History of
Smoked Cigarette
Regularly Smoking
1
2
3
4
Mortality Ratios
Insulation Workers Never Smoked
Regularly 1
in Relation to 3
Insulation Workers
With History of Cigarette Smoking 2
in Relation to
1
3
5
6
7
8
0.6 2.5 5.6 18.9 36.8 67.2
1.3 4.3 12.1 35.8 66.3 87.5
AGES UNDER 25 AT START
1.7 3.9 6.5 11.5 24.9 40.7
1.8 4.1 8.6 18.9 29.3 68.9
35 64 86 164 148 165
217 172 216 189 180 130
76 110 186 311 266 205
72 105 141 189 226 127
2.1 3.2 7.9 26.1 50.7
2.1 6.0 21.0 52.2 71.6
AGES 25-34 AT START
2.0 4.7 9.0 20.4 44.9
2.0 6.0 15.1 33.6 63.3
111 70 90
126 118
100 188 266 200 141
105 128 233 256 159
105 100 139 155 113
5.9 19.6 47.0 71.1
AGES 35 AND OLDER AT START
3.4 9.9 23.5 49.0
4.1 16.7 37.5 66.5
174 198 200 145
144 117 125 107
Source Adapted from Reference 3 Table 3
4-83
CANCER
CHAPTER 5 Edward A. Lew A.M. F.S.A. and Lawrence Garfinkel M.A.
with fat consumption and a negative relationship with
of Cancer
fruit and vegetable consumption
of
Nature
term for a group of diseases
is a generic
Other cancer risk factors include asbestos expo-
in utero
growth Cancer
disorderly and uncontrolled
to the drug diethylstilbestrol
characterized characterized
by Cancer cells unlike normal cells
sure exposure
to the sun
therapy overexposure
abnormal cells
useful tissues or
menopausal estrogen
to many substances
and do not develop into cancerous and
and other radiation and exposurcehloride and others
change change Celis of any tissue can become
such as chromates nickel vinyl
organs
of their original structure
retain some
cells usually remain at
Dimensions of Cancer
cancer
At the beginning
is said be
1986 some 930,000 new cases of cancer will
will site and the malignant tumor
to
original
During for the first time and about 470,000
not multiply- their
Ordinarily cancer cells do
stop
be diagnosed
4 out of 10 cases diagnosed
localized neighbor- to do so
may invade
They once they start
Ing
constituting a local extension or
die from it On the average
this year are expected to be alive 5 years heanncdetArbeaotuetd
ing tissues or organs
3 million Americans who were diagnosed
Infiltration
cells enter a lymph
for cancer 5 or more years ago are living today without
Eventually
some
of
the
cancer
carried
to
other
parts
evidence of the disease
or blood vessel and are
secondary channel
and start
Table 5-1 indicates the importance of the major
of the body where they lodge
cells is called
in 1986
This dissemination of malignant
sites of cancer
growths and it is one of the reasons why cancer is so
In 1986 the lung was the leading site of cancer
metastasis be confined to the region of the
about 100,000 new cases - but in
lethal Metastasis may termed regional or it may
among men -
site of cancer was the breast with
original tositseiteasnddisitsantthefnrom the original one in which
women the leading
In men cancer of the pros-
nearly 125,000 new cases
stood in second place
scpasreeaidt is called distant or advanced
tate with 90,000 new cases
rectum with
do not metastasize We still do not
cancers
and exten-
while in women cancer of the
was second Ranking third among
Some
understand what controls the multiplication
of
73,000 new cases of the rectum 67,000 new
of cells and tissues The causes sion or infiltration
men was cancer
and cervix
cases while cancer of the uterus corpus
cancers are not known many
the American
combined with 50,000 new cases was third in women
Cigarette smoking is estimatfeodr b8y5 of lung can-
The largest numbers of cancer deaths among men
Cancer Society to be responsible
The
men and 75 among women
1986 were nearly 90,000 from lung cancer 29,000
in
and 26,000 from cancer of
cer cases among
smokers is more than
of male cigarette
from rectum cancer
were over 40,000
death rate of nonsmokers Smoking has also been
double that
mouth pharynx larynx
the prostate Among women there
of
deaths from lung cancer nearly 40,000 from canccoelron-
implicated in cancers of the
and bladder
the breast and 31,000 from cancer of the
esophagus pancreas
While it has been difficult to evaluate the role ooff consumption
rectum
a disease of older adults The
Cancer is primarily
65 and
alcohol by itself as a cause of cancer
the risk of
increase
incidence of all forms of cancer in men aged
while alcoholic beverages is believed to
The
four times that of men aged 45-64
cancer of the mouth pharynx and esophagus
older was
65 and older the corresponding
combined synergistic effect of alcohol and smoking
among women aged
85 of all deaths from
was 2times About
has been easier to demonstrate
figure
55 or older and ranked second
occurred at ages
of death
Extensive research is under way to clarifyrtihskesrSoloemoef as cancer
cancer
only to the cardiovascular diseases as a cause range.
diet nutrition and food additives
relationship
in this age
studies suggest there may be a positive