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FILE NAME Kent KNT DATE 1954 Feb DOC KNT136 DOCUMENT DESCRIPTION Journal Article - Occupations and Cigarette Smoking Factors in Lung Cancer - American Journal of Public Health | American Journal of ACE & YEATCH PUBLIC onsulting Engineers awags Electricity Industry SAF Supervision of Construction lon , and Rates adway Kansas City aed, Volume 44 February 1954 BOUND IODINE TESTS Santime Server in Hospitals 6 = Ack Ins mailing AMSON LABORATORIES Philadelphia i reet estab 1974 ee Sy ha e nay a mk. | How to Use Financial Data ERSON YENABLE P. E. mish and Chemical Engineer Atmospheric Pailation Fs Program Planning Tool 5 2 A Program Director's Guide a y HEALTH Number 2 as a Basic Fifth Ave Pittsburgh 32 Pa NAL EXAMINATION SEXTOY the anol Administration Health State and Local Health Department and Merit Systems Field Condi Public Health York As ociation Association Public in Health Association loc , SEXTOY Res." ae =, Be | BSS f RESoe i el p g ' Ume are right important ways by which budgets and periodic finans rial statements may benefit the administrator and the program he Grecia They are not devices in plaque professional personnel but oy, insend , valued allies to pro- * gem writer improvement What to look asserts for and the howe Properly understood and used these res ports can be an effective servant lending a strong hand in changing program dreams into operating realities When given fleeting attention misunderstood or ignored the financing of program ele- ments may become the master of the house dictating the nature and extent a tp, be ww that information effectively te this paper's theme of professional services on an unplanned day basis thus tending to make term constructive planning pro- a re 5 Program budgets and related periodic #e. numcial reports can be an indispensable Pi + and basic part of realistic continuous Bibs am planning and direction if ci! ewd effectively by the director and his gram difficult if not impossible The director should recognizereports in itially that budgets and periodic reports of program financial condition are but two of the many basic tools usable in planning for professional services in There The benefits of brewers yeast sionally to dispute Its use bab Bay, bject 4 as umen and animal is Oe +, There appears to be little information ble in the literature to guide the | trained administrator as a director of a bureau of ma- any categorical health program Such financial reports as these assume mean- ing only to the extent that they can be interpreted easily and related directly he richest It natural nguenterrailtliyonof the estimates in complex nutri crippled namio B of and Na weeel and child health or vetlg Mr. Shapiro is a graduate student and con- ' his development of valid sultant University of Pittsburgh Graduate estimates for his health School of Public Health Puisburgh Pa omplete protein iy m special guides ing minerals bear But before you prescribe dh kal help hat all yeasts are not brewer eV dh he periculie or do all brewers yeasts mes ay =a) : o thethe higher quality and dace ontency of FOOD It difoe 5 aan only in itsits superior culture m also in the skill and know how " Fae Neither are there clear available to him interpret statements of financial con- he receives in terms of their real as related to his program Formerly be served as regional administrativi anetlinds consultant U. Children's Burean New York N. Y. This paper was presented before the Maternal and huld Health Section of the American Public Heahili Association at the Eighty Annual Meeting in New York Y. November 11 1951 149 in its production he _ VITA ig MES 134. Washington Security Ag0 P. ich ith The Age Their Chane XVIII oe a Be be . : ME: @ Occupations and Cigarette Smoking as Factors in Lung Cancer LISTER BRESLOW M.D. F.A.P.H.A. LeMAR HOAGLIN GLADYS LASMUSSEN and HERBERT K. ABRAMS M.D. F.A.P.H.A. studies have implicated cigarette smok- # of Cerebral Phy ' reciation for Us Cerebral Pal Nere Child_t Child_t . Wieveasia orders 418 Chad + 414 WASfi J This four study offers addi uanel evidence tending to connect keary cigarette smoking with canserapations In addition it liste several serapations that seem to hare some stiulugical relationship to the dis raw They need further study as is suggested ing and certain occupati* o-es- n-ess- pecially those involving exposure to radioactivein and chromate ores and asbestos in the causation of lung cancer However the number of persons known to have such occupational exposures in the United States is rela- Services for the in New England Jers 144- Legralativa Cam r Cerebral Pulp .9 it Dise Prem &- The sharp increase in lung cancer "rtalityconstitutes one of the most tacular disease phenomena of the pot two decades In the United States tively small investigation The present investigation was under- taken four years ago 1 to determine whether any additional occupations might be involved in lung cancer and sacript Publis one Dieses cal the adjusted mortality rate for lung eaarer climbed from 2.7 per 100,000 thus deserve intensive investigation and 2 to obtain data on the rule of Gretchen Musim = 3. J. Sperch1 ) 1952 . Ia = Editorial BE 7 Donald F. Bi olation in 1930 to 11.0 in 1948 a ore than fourfold increase In at least wer state California pulmonary cancer accounts for more deaths than does tobacco usage in lung cancer Methodological Considerations * of 1124 os Com 1433Q pulmonary tuberculosis and among " . males aged 45-64 it causes 4 per cent of ed deaths Definitive study of whether an occu- 7 pation or cigarette smoking is a causative factor in lung cancer requires that 7 os Attempts to explain this rising mor- ata blity as spurious e.g. as due to im- ty ored diagnosis of the disease do not poe oe and up The lung cancer death rate- the incidence rate for exposed group be determined This rate is then con- pared with that of a control population the most acceptable control being all the at hh unfortunately is still our best rest of the population from which the fags er 15.000 post Z in this field n honor of whey rthritis and # je or in one must apply for mailing sin Founda proximation of incidence rathe as teased two and a half times more rapidly among men than among women One can hardly presume that physicians Mute applied diagnostic improvements w much more completely to men than we omen Likewise the increasing proportion of lung cancer found as a cause of death among autopsies supports the conclusion that we are dealing with a real increase in the disease Environmental changes appear to der the best explanation for the phenomenon = Previously published Dr. Breslow is chief Bureau of Chronie Diseases California State Department of Pub- lic Health Berkeley Calif and Mr. Hoaglin and Mrs. Rasmussen are also associated with this departinent Dr. Abrams who Was formerly chief Bureau of Adult Health California State Department of Public Health is now medical director Health and Welfare Fund Chicago Office Theater and Amusement Building Janitors Union Local 25 Chicago IH This paper is based on a study supported by a research grant CS 9047 from the National Cancer Institute PHS and was presented before the Industrial Hygiene Section of the American Public Health Association at the Eighty Annual Meeting in New York N. Y. November 10 1953 171 4 ee aM Ale Ny: APC renenay waee n eens PREt 172 FEB 1951 AMERICAN JOURNAL OF PUBLIC HEALTH ee exposed group came Assuming the same diagnostic and reporting standards for both fey 005 } groups one may thus deter mine how the chance that a member of occupation he an exposed group will develop lung cancer compares with the chance that note the frequency of the various get pations on death certificates when i disease appears as the cause of when The frequencies of the such death certificates may then be exit R tomd of 318 : ke babe such a person would develop the dis- ees case if he were not a member of the oo exposed group If the likelihood of de- abe veloping lung cancer is substantially in- ttn creased by being in the exposed group dh e.g. a certain occupation one bth conclude that the may causative exposure is a ttitetet tt, factor in the disease The key to this ateDl analysis lies in determining comparative DAA incidence rates for a suspect group and DO a control population But first it is certificate data arise from the follow necessary to identify circumstances only one suspect exposed groups That was the aim of the present study The im- be recorded occupation while this ag be the is supposed = portance of pin pointing these usual occupation it is often se arises from the fact that groups incidence correctly recorded and duration in & occupation is not recorded studies require assembling sizable populations and observing the occurrence of circumstances tend to blur thAell the disease in them large and ex- cation of suspect occupations from d certificates pensive task If for example data were obtained implicating occupations . . The method selected in the pred beyond those already known to be study was to determine the life occupational and causative factors in lung cancer one would be justified in assembling popu tobacco hist R of lung cancer patients and a com cae group by actual lations of the occupational groups and observing them for lung cancer inci- interview with s ath patients The work history included ee" dence rates study which would de number of years engaged name of velop more definite pany industry a description of du~ proof presence or absence of of the and listing of products and hazarde om Ben relationship an etiological materials known to the patient Several methods of investigation have advanced our knowledge in this sphere First is clinical observation of associa tion between a case or a few cases of lung cancer and some exposure e.g. asbestos One defect of this method is that such clinical observation depends largely on chance and often involves such small numbers of cases that the ovaflicdoiutryseissuqcuhesotbsieornveadtionWshere made are helpful Another cominon method of identi fying suspect occupations in a highly fatal disease such as lung cancer is to Data Collection general hospitals five veteran or cous lary two university and one hospital comprised the prima An interviewer study grow especially qualified i occupational analysis obtained the dal from cach patient in the cooperati f: hospitals whose condition permitted 5 &4 interview The session with each tient often lasted two hours or mon p since many details about smoking m ane ere wee ts Gudlg ce : ene! Ee aN ale ay i|a aA : * a LUNG CANCER VOL 44 173 & the various occs Juinal and the information about Method of Analysis tificates where the he cause of death h^' occupations os + may then be con ill death certificats dation If certain with much greater ertificates for lung licates where death . one may conclude Ee " . +, recupation recupation was highly detailed A total of 518 patients who finally had hathologically proved diagnoses of long cancer were ultimately included in he analysis For every patient in the case series her patient admitted to the hospital abet the same time the same age within five years sex and race ondition other than cancer or a chest Each record was reviewed by a physician particularly with respect to the pathologic diagnosis An industrial hygiene 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 may be involved sively investigated X darae was chosen in a random manner > @ a matched control Two inter- Attempts to analyze the data concerning type of industry and exposure to ats may be credited method Howere ts one working in Northern Cali rnia and one in Southern California materials already identified as toxic or carcinogenic did not prove fruitful h this use of deathi pitals obtained the data from the from the following _ = cancer patient and control patients Hence the major analytical effort with respect to work history went into the ne occupation may this is supposed to _ wing the same schedule in identical manner That interviewer bias did not data on occupation itself This had been coded according to the Dictionary ion it is often net + meer into the determination of tobacco- of Occupational Titles 2nd ed 1949 SS nd duration in th * age history seems likely among other prepared by the Division of Occupa- corded All the frason because the results closely tional Analysis U. S. Employment blur the identif parallel those obtained in other investi- Service a code with 367 three pations from deau FS , gations where such bias apparently was titles Particular attention was devoted > to the question of years of exposure be- excluded and because the results for ted in the presed the lifelon the two interviewers were very similar difficult to conceive how inter- cause present knowledge of carcino- genesis due to environmental agents in- mine ~ usage history swer bias might have affected the dicates that duration of exposure and a nts and a contra long latent period are critical factors interview with the sccupational data since both lung Data on tobacco usage were analyzed rancer patients and control patients included the i> so as to reveal the type and degree of history _ rationed hundreds of occupations and smoking as well as the fact of smoking aged name of com *", one of these was suspected by the in- itself scription of dutie cts and hazardos wiewers Preliminary findings were Finally an attempt was made to sepa- he patient hept from the interviewers until the rate the effects of tobacco usage and nd of the data collection occupations which appeared implicated during 1919-1952 - pitals three count mil ve veteran or mil 4 and one privez the study grow cially qualified me obtained the da in the cooperating - . lition permitted sion with cach vo hours or mon shout smoking " Table Age Distribution of Lung Cancer Patients and Controls Age Total Under 40 40-49 50-59 60-69 U and over Adenocarcinoma 8 3027 3027 3027 14 4 Cases Other Types of Carcinoma 472 22 56 194 151 46 - Total 518 28329 28329 28329 28329 28329 Controls Total 518 51 ony OS iA oe pant: Foren ns Pele tad re ttn REVESiRa E err 174 FEB 1934 AMERICAN JOURNAL OF PUBLIC HEALTH Table Sex and Race Distribution of Lung Cancer l'atients and Controls Sex and Race Adeno- carcinoma Cases Other Types of Carcinoma Total Controls Total Total 46 < 538 518 Total male 27 38 493 493 White 41 38 461 461 Negro os & 20 py.) Other ! = 12 LR Total Female 4 White 3 Negro 1 Other oe Findings on Smoking Tables 1 and 2 reveal the distribution of the lung cancer patients according to their biological characteris-tiacgse sex race and the essential similarity of the matched control series in respect to these characteristics Tobacco usage by lung cancer pa tients and the control group is shown in Table 3. Here one may note that 481 93 per cent of the cases gave his 22mm 25 3 22mm 18 18 drrat for 22mm 4 4 Fe 22mm 3 3 the A. ay a * he two series oS This suggesti ~ hypothe tories of having smoked (awww only is cigaret niu: ,, ligations in whereas only 394 76 per cent of ligations the controls gave a similar history No mits hi greater frequency of tobacco usage other forms pipe cigar chew iz arrinoma m snuff occurs among the lung a8, 113 patients when compared with per the em! ro: brencarcinoma trol group In fact 08 of the contre ; 3 quate: wherea group used tobacco in a form other tha per cent of Ane cigarettes exclusively whereas only EF pe of carcino +4 of the lung cancer patients did x relative frequencies which are t,o not mdr.oe quamous Dated, did not Mice * Owe common Table Tobacco Usage During 20 Years Prior to Study Reported by Lung Cancer Patients and Controls :M . Cases Manner of Using Adeno- Other Types Tobacco carcinoma of Carcinoma Total t TotalTotal Total not smoking cigarettes 1616 172 518 6 28 34 . Charette Smoki f 1 haracteristics haracteristics : { No use of tobacco 4 15 19 j et i Tobacco other than cigarettes only 2230 13 t Renal rigaretto amo } Meas 15 grate of | ., Total smaking cigarettes 2230 ... ... g sas n 2155-y2e1ars of Cigarettes Cigarettes Cigarettes only only Cigarettes and other 2230 ... 146 ISS da e 240 3% da before bre 154 ' ,IM qgarette rough LUNG CANCER VOL 44 175 Table Amount of Cigarette Smoking During 20 Years Prior to Study Reported by Lung Cancer Patients and Controls Packages of Cigarettes Smoked per Day = Number Cases Per cent Controls Number Per cen Totai 518 100 518 100 Nane 34 7 124 2283 < 4 50 2283 .4 34 105 2283 l= 59 199 2283 2 or more 80 15 22 * Not recorded 2 18 3 Lerent for the nonusers of tobacco in This two series This suggestion of an effect by cigtes only is consistent with other in igations in the field Some support fer the hypothesis that cigarette smok beg affects the development of epithelial marvinoma of the lung more than ade- carcinoma may be noted Six out ed 46 13 per cent of the cases of nocarcinoma did not smoke cig arettes whereas only 28 out of 472 16 per cent of the patients with other typeosf carcinoma described variously m squamous epithelial undifferented did not smoke cigarettes One commonly used measure of the ment of exposure to cigarette smok- ing the average number of packs smoked per day appears in Table 4 Seventy per cent of all lung cancer patients reported smoking one or more packs of cigarettes on the average per over the preceding 20 years compared 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 before breakfast and whether or not he inhales Table 5 reveals that by all Table Age of Beginning Cigarette Smoking Smoking Habits and Cigarette Cough Reported by Lung Cancer Patients and Controls 118 28 56 68 _ 94 2 54 Gearette Smoking Characteristics Number Tmal Tatal cigarette smokers Began 15 years of age Began 15-24 Began 25 years of age Iskale le before breakfast Garrite_cough Garrite_cough 51B 481 166 2HG 32 4.19 373 At Cases Per cent Based on Cigarette Smokers Only = cent Based -- -- Tutal Number Controls Per cent Based on Cigarette Smokers Only 8287819 8287819 8287819 8287819 8287819 8287819 8287819 100 93 32 55 6 80 72 39 518 394 116 213 35 327 229 112 100 29 62 49 83 SA 28 Per cent Based on Total NISJANZ NISJANZ NISJANZ NISJANZ NISJANZ NISJANZ NISJANZ NISJANZ ad caer ran tte qies r la a & 4g G eo 4 4 FT ged * EP fate ioe _ 176 FEB 1951 AMERICAN JOURNAL OF PUBLIC HEALTH Table Estimated Prevalence Rates * of Selected Ages and Various of Lung Cancer per 100,000 Malm sea Cigarette Smoking Habits : Number Estimated Prevalence Rates Quantity Smoked Daily Lung Cancer Control Heavy All Quan tities None Patients aged 50-59 years 1. Doll and Hill 276 275 Ex 2. Wynder and Graham 58 74 258 3. Sadowsky 210 Ex 58 74 Gilliam and Cornfield 208 3" 4. l'resent Patients IIRR aged 60 6y9ears 198 213 213 3" 12 "" Beead lung 1. Doll and Hill cancer 197 cigare 2. Wynder and Graham 187 22 28 on i wo of 16U 22 " 3. Sadowsky Gilliam 28 : on 5 2 len. Suc and Cornfield 76 Puhe ** 4. Present 71 22 22 | 168 169 S 9 (he statistic 22 22 17 Mer statistic 25 Estimated " Sadunsky Sadunsky scearding Gilliam to the method of Commbeitdt Date for for data Quantity smokeadnd Cornfeld from the latter paper studies of Dull sed llill Wynder sad cigors converted daily except for present study ie all forms to their equivalente in of a day 2. Wynder and Craham cigarettes as Jellows 1. Doll and Hill Cornfeld i cigar = 10 ciga=r 5 eigoratten I pipeful = Mt om edt Sadowsky includes only cigarette cigarettes 1 oz pipe tobacco = 20 2 cigarettes and S. cigarettes 4. Calla answer to smoking dues ci Relative prevalencs to the ratio For present study quastity mpeual aX aerer thee dues dues se Heavy ambung smakers rate among nonumokesaG ** Ileury amusing is defined as the sad till or following number of more 2. Wynder and Graham 4. present study or moN ar mote cigarettes or equivalents of 3. Sadowsky Gilliam and cigarettes per day~-ml Cornfeld oan, oy 28 OF of these criteria the lung cancer tients smoked cigarettes to a greater peax-- tent than did the control group Also approximately fifths of the lung cancer patients stated that they had had a cigarette the cough usually antedating onset of their illness by many years 120 said that they had had five a cough for years or more The frequency of such cigarette cough was only about half as great among the control group and only 39 of the control tients indicated that their pa- lasted five cough had years or more Significance Smoking Significance of Findings Findings on Cigarette The data clearly show cigarette smok- ing to be more frequent and intense among lung cancer patients than among ca A the control group Our data para that of other recent well contra studies all indicate a tion between positive cordis cordis cigarette smoking and be cancer a correlation which incru BSEE)E, steadily with the amount of cigar 5. smoking One can hardly escape Bey) conclusion of Doll and Hill Ban t smoking is a factor and an imporitn ae factor in the production of carcine of the lung and the more recentcarcine clusion of Doll The results amoa believe to proof that a cause of bronchial smoking i carcinoma hae The cigarette smoker or cigarette prospecti | cigarette smoker may wish wish to know much his chances of {7 developing cancer are increased by such smoki | AcknowledgingAcknowledging that a correlation ere one may still inquire how tz does cigarette smoking inmcraenayse yoy: 1182961653 1182961653 1182961653 1182961653 1182961653 Authors edit Ship captain Clerka gene Canvassers a Mimmen to 1182961653 1182961653 Waiters and Policemen , 182961653 182961653 1182961653 Animal and Farm hands General wou 463213 463213 463213 463213 463213 463213 elsewhere Painters exci Brick and sto Construction Lacomotive fi Attendants it Mechanics an es Sample read quements 1 Wee mbed accord ay Guteagpe, C. U. Log en Pad Su o hae Je + : vr cid wants pms ome s seca cucttmennidke 6Siobem 6 ea a ale wane EN, A NA pte ead ens AON te E TEs myeee 2 ark 9 fs ere emer LUNG CANCER yYOL 4 17 Further crease likclihood of lung 44 crease cancer Edhood of lung the likelihood lung Edhood a a As likelihood likelihood absolute answer questions Application Cornfield's Cornfield's formula questions Application Application Application studies studies including ive ive eres? ? To that records of present data from that ncet - Maitely Maitely would require numbers of for present Table Table indicates All dsrette smoking for numbers aged 50-59 50-59 the prevalence prevalence of i AD j Que Que lung cancer age Quin tities procs embled in the persons would lung cancer times from four 11 great among among among non- tities tities embled embled These smokers among smokers smokers as Ye grette placed categories categories respect respect among heavy seven 27 times nonsmokers y? smoking smoking great heavy smokers as among & .gx grette smokers and smokers nonsmokers were found Ho: 2 Tally rate for for 60-69 age group aes Tally int length would observed observed for involves the assumption group This formula formula formula , edxient lung length of time determine determine history assumption concerned far as ; - cigarette among various smoking concerned the pa- ye of aries of smokers and tients are are representative all BR earraries mokers Such smokers lung cancer cases and representative sample is Lo and ) studies studies now a representative sample of controls controls are population wart However have been sons in the general loped data such investigation investigation investigation which those those the * ment certain asumptions one one Findings on Occupations .MH evievind m vivid aanswker eto assumptions As noted earlier the records for lung Le GilllaGilmllam ; 4 mokfa a times does cigarette smoking how yeid y smoking in- times does cigarette and controls showed lung cancer patient Gillesaslkk, t+ was Key Del dey. Ded 3: wore; ead from Complete List of Ocenpational Ocenpational Groups GrEmopulopysed EWmphloiycedhThere Were at Least 5 Cases CCoonnttrroolsls Employed for 5 Years or M^,re Cases or 5 Persons Employed in Occupation Least Least Years Years 2 correla corela and lung Occupation Cases Controls = e increases 7 9 : cigarette cigarette scape the fill important important carcinoma carcinoma 4 cecent amount that important important carcinoma > : ; 105 Clerks captains mates pilots and engineers 155 Canvassers Canvassers solicitors solicitors . consumers 180 Salesmen to 27 Waiters and consumers 6 307 317 433 317 316 Policemen and detectives family Animal and livestock public service animal and livestock service Farm acetipations General woodworking woodworking acetipations elsewhere elsewhere classified acetipations Painters except construction maintenance maintenance and stonemasons elsewhere classified 532 Construction occupations occupations not elsewhere elsewhere 12 Locomotive Locomotive fremen and parking classified S80 Attendants stations 583 Mechanics repairmen classified Ya Attendants, filling stations elsewhere elsewhere wccupation which deration Sampin randomly selected 81 8 2 3 7 bt 6 6 10 8 3 $ 45 3 1 15 8 8 11 4 10 3 5 10 7 6 1 25 6 9 lo Occupational employment employment Occupa- Occupa- . D. Employment Employment categories in the Dictionary Occupational Titles Service , 1919 with 5 years OF mere Titles (And ed.). Washington dersiven requirenents {ut Employment Employment Service in the Di:tionary of Orewpationa) wey according Vo 3-dtgit eategueive 191% unas clesibedD. Cz U.S Empleyarat servece, Tasbiagion, porn 4Tos ~ . ow er a - owe <) Pav = ener ee nae ep ie we a ca / ee i , io 7. * + ; : , ' , ot . Pao , ., q ; } ] 1 oe "1 . 1! i 4 . - 43 "4 } . 4. . t 178 FER 1934 AMERICAN JOURNAL OF PUBLIC HE . Table Occupation Grongis in Which the Frequenes Employment Among Cases Was at Least Twice ta Great us Among Controls of 5 as Year 4 ample one oct " 530 plumbers bi fitters showed amis Kisplayeidn with a five i Occupation Oertrpation at Least 5Years Examination < records revenic Cases Controls , the difference b 016 138 266 4.30 473 Engineers civil Stock clerks Policemen and detectives puldie service Lumbermen raftsmen and wood choppers Machine shop and related occupations not i I i 3 t 3 it 5 elsewhere classified 485 Welders and flanie cutters Occupations 20 in production of petroleumi 523 Construction machinery operators not 13-2 13-2 ^ 13-2 elsewhere classified ; 315222 524 Brick and stonemasons and tile setters 3 31522 538 Brakemen railroad 10 315222 process 570 Firemen other than fremen 31 315222 573 Crancmen derrickmen hoistmen and shovelmen 15 315222 575 Drillers extraction of minerals and construction 7 315222 ' Deropations classified according to the Dictionary of leropatinual Washington D. .: U. Employaient Service 1419 Includes only occupations at least 3 cases with 5 years ne more al emplesment emplesment Tilles 10 which 2nd ed there were Fe b : : series was due had a heavy e was also noted involving involving asbes quently in the cases than amo ^': lory - including : of controls steam boilermake k, and boilermake - sure to asbestos- times among t 7 time among the time Table 9 ; Lions groupgrouepedd . significant expo F bers in each of f the differences . occupations . trols appear to i followed their occupations followed and their dura- tions in years A listing was prepared of the occupations pursued by at least five patients or controls for live years pertaining "' the numbers pertaining to any one o cupation would be less impressive thas & in the case of cigarette smoking How ever the frequency with which the lung 3. differences of Ested It is o veral of those those differences invol particles and fr or more This listing revealed 81 occupations in this arbitrary frequency duration category Table 7 presents a random sample of these occupations and the number of patients and controls who at some time cancer patients had pursued certain pe cupations was substantially greater than f. the frequency with which control pe tients had pursued these same occups F * tions _ e, The occupations for which the fre B- metallic combus to TynTdyenrder corrobo and Gra Table during their work history had been en- quency among cases was at least twin gaged in them for five years or more It will be noted that among the 518 lung cancer patients seven had worked as authors editors or reporters occupation for five years or more and among the 518 controls nine had been similarly engaged Relative frequencies occupation of would appear to have the same logical significance as such fre- quencies of cigarette smoking The lat ter is of course much more cominon among both case and control than is any single occupation groups Hence as great as among controls using the 8. same frequency category before appear in Table 8. Such a tale # lation of course shows the occupation 1 code classified according an arbitrary which was not devised to reflect com mee 5. 1. Welders a mon occupational exposures that might BP? be responsible for lung cancer Furthe Bay analysis therefore included the de &- Steam fitt 4. Occupatio and cop tailed examination of records of i & dividual cases and controls and a Coo7. kConsstructi grouping of occupations according& possible common exposures For a B23" , . 5. Marine en * Orespation detailed esaM~ RG~ iat wx * io *, * ; Ray Se 3 wane We . a * aga MEeeE he Le C4 oe Sr Tey . sad a NES : erd et ; % S: Th |: LUNG GANGER VOL 41 179 -15 Year * | & i BF , one occupational group number, occupations may be involved in lung plumbers gas fitters and steam cancer dom! showed 16 cases and 10 controls In recent data of Doll the only Employed in Eon at Least ae Semination a year employment history 2 tO Semination of these 26 individual important occupation with an excess in the cancer group was that directly con- Years Aeweed revealed that substantially all cerned with the production of gas Little Controls = & ference between case and control or no support was found indicating that = riiry nd was due to the steam fitters who other occupations suffer special risks nd upon 1335 ~cARPE o heavy exposure to asbestos It However Doll's study was based nd 1335 3] eae ale noted that other types of work experience in England where the em- 1335 TgR ee + ing asbestos occurred more fre ployment pattern differs from that in 1335 3 dy in the employment history of the United States especially California , 312 312 312 my eae than among the employment his Also Doll used an occupation code of 73 "1 Wy of controls Thus a new category \ only 76 categories which may have been fing steam fitters asbestos workers too coarse to reveal the differences oak BAe wd Boilermakers involving expo- | found in the present investigation where 04M%F ane asbestos found to occur 10 te | ot tig among the cases and only one cs among { See among the controls a code of 367 categories was used and analysis carried to subgroupings of these Table a us 9 presents the data for occupa- It may be noted that 77 persons with grouped according to possibly lung cancer had an exposure of more wR 100 2nd ed cant exposures Although num- than five years to suspect occupations which there were bf SmLernces each of the categories are small unduplicated count in seven occupa- a} fe Lerences between cases and con- tion groups according to the data in Bix tub appear to implicate the occupations - * if It is of interest to note that appear that ng to any one itamg, autead of those with the most striking | ss impressive that {ead Commences involve exposure to metallic How | le smoking X es and fumes and products of ith which the g . we combustion This observation Pursued certain than tially greater than which control p G toto corroborate the suggestion of Ypder and Graham 13 that hot metal Table 9. This number represents a not insignificant proportion of the total 518 lung cancer patients in the entire study A further question upon which the present data might be expected to throw some light is the extent to which cigarette smoking and occupations operate occupi #2 hese same atay Ben which AS ne which the for was at in eve least twi oar , Years in Table Cases and Controls Employed for at Least 5 Years in Selected Occupation Groups * controls using tahtes ation category PX A; ave Persons Employed in Occupation at Least : le 8. Such a tab ms ike: Occupation 5 Years ws the occupations im vo an arbitrary and 4% sed to reflect reflect might posures that com Be might ee | ss ng cancer Furthe Zoe! Welders doing welding sheet 1 Welders and metal workers doing welding 1. Steam fitters Loilermakers and asbestos workers Ele ctric bridge crane operators industry 4. Occupations in the extraction of lead zinc Cases 11 30 S Controls 2 1 I de: #e5% included the copper ore 3 wipers Marine 223 of records Oe t Marine engineers firefmen iremen oioilerls ers and and wipers 223 br a & Construction and maintenance painters 223 12 and ee: controls and oe Pe 11. Cooks commercial excluding cannery cook- : 223 21 g ys WES) 5 Orespation groupe haw'd im and esamination of veruci^n regrouping areording in common Pa perspational exposures alter I Ron ie be a 5 O., ae "hea WOT TANS O02 begs q We ued S 4 Aine md die pas MM 24 << 4 thee & ee the BEE : rey ere ! Fonte a * Wad ye ay eas St: :ane ' 4 bart p;whew MF ye ove ive _ y, : 7.- robe! : 2a. had : OM . SAS Zp Re inita Se abies & dite pies poser ect eae Bis irs SaaS sc ay a et pid, ' : : . oot . . oo *s ; .. ' (4 a a 180 FEB 1954 AMERICAN JOURNAL OF PUBLIC HEALTHI Example Table : of Adjustment for Smoking Applied to Welders sand Sheet Metal Workers Doing Welding Packages of Cigarettes Smoked per Day None 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 8. Expected number of welder cases 22 110 132 0.167 0 1 1 0.267 % fl fl- . 285 69 285 105 285 174 296 193 489 2 or Notre- Notre- corded Total 80 2 102 BEE 493 BEE 493 BEE 986 0.263 0.396 0.605 0.783 ; 0.357 16 ) NO2 ] I 0 14 0 NO2 I 0 0 2 0 NO2 12 1 0 0.0 0.792 7.260 0.783 0.0 9.002 Expected propertion al coms among welders = : 9.007 = 0.563 16 14 Observed proportion of cases among welders = - = 0.875 16 Ninety per cent con proportion cant level dencelimits for the 14 = 0.617 0.988 0.988 Femalon excluded from total 16 Obtained by applying the group siner only mairs are included in groups to zumber of welders in proportion of cases among total cases and and controls that smoking category line No. 4 ^ line No. t Hald A. Statistical Tables and Formules Note This test aian 7 New York John Wiley 1933 was applied to all other statisticallysigni^"rant at which test was applied in each stucking entegory occupation bollermakers asbestos workers was on other groupe met the 95 per cent level groups knows in Table 9 the borderline of statistical signi^"rager at the 95 The group Keam of Ratistical meni^-ezner per cent level None 15 pe ta the Sitter si the . 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 ~ differences In the other occupational groups the numbers are such that the might arise from chance variation more than five times in a hundred However all the occupations listed in Table 9 deserve intensive study to determine their precise relationship to lung cancer One important step is to : assemble populations of individuais em $ ployed in these occupations and with &: varied smoking histories in order to observe their lung cancer incidence rates These rates may then be com & pared with the rate for the correspond ing age group in the general & population One may thus determine 5 occupation those prev etiological in the d These occ tensively s extent per a special . after if a clearly esta Journa2l ADDENDI on the com an eight Journal Rav of health ed January issu education Li been the auth years it havi how being in a particular occupational group affects the chances of developing lung cancer and likewise how cigaretle smoking modifies these chances 3 4 LUNG CANCER VOL 41 AI and mechanism responsible should be identified in order that protective meas- ures may be introduced REFERENCES Conclusion 1. Daft M. E. Still R. and of the Lung in Relatios 14 :) 1951 Kennaway E. L Imboere Brit J. Lancer Cancer study The data in this constitute still another link in the chain of evidence lung connecting cancer with cigarette smoking evidence which the New Eng land Journal of Medicine notes to be " strong as to be considered proof within the everyday meaning of the word 14 It is time for those concerned with health education and with the advertising ethics of at least in journals health and medical to take note investigation Further should seek the cigarette exact component of smoke- tar arsenic or which is respon- sible The data also suggest that 2. Schock R. Baker L A. Ballard C. Dolen S. Tohsern .. Smoking an ao fuelmeiral For he in Disease Canery Nemateb Nemateb 49 3. Wynder F. L. and SA 1950 Graham E. A. Toberen Smok ing te Possibile Eriulmgic Facing In fleune hampetje Carcinoma A Study al 643 Provedd Cases J.A.M.A. 143 329-336 1970 4. Doll R. and Hill A. A Study ni the Artiningy of Carcinoma of the Lune Brit M. 2-1271-1286 1933 Coldstein 5. Levin M. .. Cancer and Tobaero 11. and Gerhardt P. R. Smoking A Preliminary Re port J.A.M.A. 143 336-338 1950 6. upper T. C. Occupational Tomors and Allied Diarr Diarr Spring^eld Ill Thomas 1912 7. Rosloski .. Soup E. and Schmerl C. Die Dergkrohbet d^,r Erzbescleuis in Sachen Schneeberger Sehneeberg in Krebsforach 23-360-681 23-360-681 Lungesbreba 1976 2tbr 1 8. Mackle W. and Gregoriosa F. Cancer of The Respiratory Health System in the United United States = Pub Rep 1114 1128 1948 9. Cl^,yne 5. R. of Pneumocasionik Histological Histological Survey Necropsy Material in 1705 Cases Lancet 1931 810 several occupations Table 9 in to 10. Dell A. Bronchial Carcinoma Incidence previously adhdaivtiionng ' those identified as an BIORY Part I and Part il 583-590 19:53 and AetiBrzt J. 571-1977 etiological relationship may be involved in the development of lung cancer These occupations should now be in- tensively studied to determine to what extent persons engaged in them suffer special risk of lung cancer There- after if an etiological relationship is clearly established the precise exposure 11. 12. 13. 14. 126 Estimating Cornfeld A Method of Rates from Clinical Data Application the lune Breast and Ceris J. Nat 11 1275 1951 Comparative to Cancer of Cancer Inst Sadowsky D. Gilliam A. and Cornfield J. The Statistical Association Netwers Smoking and cinoma of the Lung Ibid Car Wynder E. L. and 1237-1278 1973 Graham E. A. Etiologie Factors in Bermehingeme Carcinome with Special to Indestrial Exposures Report of 857 RefereRTE Arch ladust Hyg & Proved Cases Orcup Med 271 1931 Editorial Cancer of the Lung New 3led 465 4616953 England J. 1056 aine aine aine Journal 25 Years Ago ADDENDUM to the January 1954 25 Years Ago In addition to the articles on the common cold mentioned last month the 1929 1929 Journal an page booklet That Mean Cold p 4491 describes Journal Raymond S. Patterson It by present associate editor of the of health education for the John HawnacsocrkepoMrutteudlayl hLiisfefirIsntsurpanrceoduction as director January issue p 94 having reported reported his Insurance Company the education Life Conservation Service Service of that appointment as director of health been the author of A.J.P.I.'s Annotated company Public Dr. Patterson had already years it having first appeared under his Health Bibliography for several line in March 1926 et w ies,. Toe a 5 stew own a : an a a =? SL hf teah-> a ta se 7 aes . . are oe Oe ~adama. Pe tae 5 Seas gee rer Te EE it x 54