Document pOZDpVbz4yELYQ6KLnOmBgoj

PLAINTIFF'S s EXHIBIT DC-85 II . I Asbestos Exposure, I Smoking, and Neoplasia Irving J. SclikofJ, MD; E. Cuyler Hammond, ScD; and Jacob Churg, MD Asbestos insulation workers, as a group,-have a high risk of dying of bronchogenic carcinoma (about seven or eight limes expected). V.'e have observed 370 such work* men from Jan 1, 1963 to April 30, 1967. Our findings indicate ihat asbestos exposure alone is not the entire explanation. Of 87 noncigarette smokers, none died of i* bronchogenic carcinoma. Of 2C3 workmen with o history of regular cigarette smoking, 24 died of bronchogenic carcinoma, although only three were expected to die of - this disease. Calculations suggest that asbestos workers who smoke have about 92 times the risk of dying of bronchogenic carcinoma as men v.ho neither work with asbestos nor smoke cigarettes. Vi'e ccp.clude that asbestos' exposure should be minimized, that asbestos workers who do not smoke shouid never start, and that those now smoking should stop immediately. . Tnl964, we reported on deaths occurring between j_ Jan 1, 1943. and Dec 31, 1962, among 632 members of the International Association of Heat and Frost Insulators and Asbestos Workers.1 All of these men had been occupationally exposed to asbestos dust for many years. Their death rate from lung cancer was found to be 6.S times as high as that reported for the general white male popu lation of the United States during the same years, with age taken into consideration. Three of the men died of diffuse pleural mesothelioma and one died of a neoplasm histologically suggestive ot peri tonea! mesothelioma.* This was of interest since mesothelioma is a very rare disease in the general - population but is reported to be associated with exposure to asbestos dust.*- In addition, their death rate from cancer of the stomach, colon, and rectum was higher than expected; but this may have boon Krom Ihe Dcp.irtm'nt of Cmiimimty Medicine. Mount Sinai School of .MiJicinc S.-likot! ami Ciiur*j. and the Depart ment of ICpidfir.ioJocy ;ir.:i Mulshes. Ainrricun Cunccr Society (I>r. Haniimmri), New York. Ke.v.i ivf'iro n joint nui-tim; of the Swoon on Dir4*aic* of the O.cM 5Jc n I'rcxir.livv Mtti.<?:* ami trie American Cotlc'di* of CfuM .11 the IJClh annual ainuniiuii uf the Am rival 1.1 non Atlantic Oiv, NJ. Junr )*, H^jrint .*!., iv Mu:nt N*fi'U S of Mvcin :*.t\ lernh Street and JMth Avenir, Nc* Yufk tDr. Sc2:::o"). due to chance, the number of such deaths being small. During the latter part of the study, we ob tained information on the smoking habits of most of the survivors, but we could not obtain reliable information on the smoking habits of those who had died at an earlier date. Therefore, we could not at that time investigate death rates m rela tion to smoking habits and exposure to asbestos dust which were considered both separately and jointly. There is abundant evidence that cigarette smok ing leads to a high rate of death from lung car.cer in the absence of occupational exposure to asbestos dust.11' Our findings outlined above suggested (but did not prove) that exposure to asbestos oust may lead to a high rate of death from lur.g cancer in the absence of cigarette smoking. If the latter be so, then the. combined effect of both types of ex posure might or might not be equal to or greater than the sum of the two effects. On.the other hand, it was possible that exposure to asbestos dust in creases the risk of lung cancer among cigarette smokers but does not lead to lung cancer among r.onsmokers. The present study was undertaken primarily to investigate these possibilities. In addition, we wished to obtain more information on the occur rence of mesothelioma ana gastrointestinal cancer among asbestos workers. Material From records of New York Local 12 and Newark, NJ, Local 32 of the International Association of Heat and Frost Insulators and Asbestos Workers, a list was made of every man who was a member of either one of these locals on Dec 31, 1942. or who joined between that date and Dec 31. 1962. No one was omitted regardless of his subsequent work history. Personnel data from union records indicated that of the G32 on the union rolis on Jan 1, 1913. 339 of the men had first been occupationally e\po*t\l to asbestos dust prior to 1922, and an additional A 17937 JAMA. Apr:I S. * Vc! 3 U? Z 10/ 2S3 men had first been ex posed between the be Table 1.--Subjects Clashed by Are as c! Jan 1. 1553, and by Years From First Occupational Ea pcs ere to Asbestos Oust uo to Jan 1.1963 ginning of 1S23 and the end of 1942. All of these men were successfully traced through Dec 31, 1262, and 262 of them were found to have died up to that time. Of the 262 deaths, seven oc curred prior to the 20th anniversary of the man's first exposure to asbestos A*>. Yr 35 39 *5-49 50*54 55-59 60-64 (549 70-74 75-79 80*94 Total Total * Subjects 2 13 32 109 80 42 49 38 21 4 370 ' 20-24 2 12 17 ... ,,, 31 Mo. of Tears Smce first Eiposure to Atbctiot 25-29 mmm 1 2 1 1 1 * 1 30-34 13 to 16 3 1 * 113 35-39 * 21 34 11 10 3 40-44 * * * 19 16 12 1 1 59 45-49 * 1 18 6 S 1 39 504 . * 2 17 IS 2 36 No. of 52 Ms 1 2 18 11 16 17 16 6 3 54 dust and 255 occurred after the 20th anniver sary. Thus, of the 632 men, 370 were stiil living on Jan 1, 1963. These 370 men were the subjects of the pres ent investigation. Table V chows their age distribu tion as of Jan 1, 1953,and the lapsed time from first exposure up to that date. All of them have Table 2.--Subjects Classified by Age and by Smoking Habits on or about Jan 1, 1563 AS*. Yr 35-39 40-44 45-<9 50 54 55-59 60-64 5-69 70-74 75-79 0-84 m Total No. 2 13 32 109 60 42 49 38 21 4 Mover Smoked Regularly i 2 2 12. 6 7 6 7 3 2 Pip*, Clear Only i 6 5 4 8 7 7 1 Ei- , cigareftt Smefccrs* Current Ci*arelt Smokers* 1-9 * Oay 10-19 Oay 2039 s Oay 40+ a Oay .1 2 5 4 S * * * 12 12 26 3 S 33 24 16 3 20 10 IS 1 11 4 17 * o. - 4 9 S 12 1 4 4 . 3 6 1 3 1 1 been traced, and 94 of Total 370 40 39 101 5 17 97 63 them were found to have "Includes eic*retie smokers who at&o smoked pipes or tigers. died during the four-year and four-month interval from Jan 1, 1963, to April 101 were excigarette smokers, five currently smoked 30, 1967. one to nine cigarettes a day, 17 smoked 10 to 19 Beginning in October 1952, we made arrange cigarettes a day, 97 smoked 20 to 39 cigarettes a ments to examine these men periodically, once day, and 63 smoked 40 or more cigarettes a day. every six to twelve months; the interval depended The smoking habits of the 370 subjects were upon age and physical condition. The examinations compared with the smoking habits of a large num-. include chest x-ray films as well as physical ex ber ci men selected from the general population.' amination and cover pas: and present smoking There were proportionally more cigarette smokers habits, occupational history, medical history, and among the 370 subjects than were found in the current physical complaints. Altogether, we have general population sample; age was taken into examined 33S (51.4 = ) of the men at least once consideration. and have repeatedly examined most or those who Causes of Death.--A copy of the death certificate are still living. was obtained ior each of the 94 deaths. In addi Information on smoking habits was obtained by tion, we examined hospital records, postmortem personal interview with the 336 men who were ex findings (41 cases), as well as the surgical and amined. 0; the 32 men who were not examined, pathologic reports when surgery was performed (39 six told us their smoking habits by telephone and cases). We also reexamined histologic specimens. five gave us the information by mail. The local It was found that the death certificate was inac union secretaries (who personally knew these men curate in 14 instances. However, this did no: niter well) ascertained the smoking habits of IS men, the picture as much as might nave been expected and family members supplied the information or. since there were several compensating errors. For the remaining throe men. This accounts for all of example, in one instance the death certificate in the 370 men. Table 2 shows their smoking habits dicated bronchogenic carcinoma as the cause of on or about Jan 1, 1963, the men being classified death while a review of the histologic spc-cimcr. by their ages on that cate, even though some showed that death was due to pleural mesothe changed their smoking habits between 19G3 and lioma; but in another instance exactly the reverse 1957. was found. Likewise, review in one instance re Of the 370 men, 4S never smoked regularly, 39 sulted in changing the reported cause of death smoked or had smelted pipes or dears but never from bronchoeonic carcinoma to cancer of the smoked cigarettes regularly, and 265 had smoked stomach with metastasis to the lungs while review cigarettes regularly, riomc of those with history of ir. another instance tesuited in exactly the oiv'-itt: cigarette smoking also smoked pipes or cigars. Of change. The 94 deaths were ascribed to the follow- the 263 with a history of regular cigarette smoking, ing causes: bionchogcrcic carcinoma, 24; pleural JAMA. April 3. 1903 Vot 2C4. tlz, 2 Ai7933 105 Title 3.--Observed 3ni t.;ecsctf Numrer cf C-ddftj Arr.crg 370 Astestos Webers During tne 2-Mcr.tn r-riod C>ui t( Dnlli Tol*!. cancer (all ule*) Cancer ef lung. pleura. bronehui, and trachea Brenchocenic carcinoma Pleural mesothelioma Peritoneal mejeine**om Cancer cf stomach Cancer of colon and rectum Cancer of all otntr sites combined Asbcslcsit Heart and circulatory disease including stroke All other causes of death Total, aft causes Observed Deaths 49 Cipectrd Deaths* U 27 2.3 24 t 3t 71 3 0.6 S - IX 7 IS 22 28.5 S >0.4 94 473 'Bata coon US msrtai-iy eoto siktcgoomc imourt nasit*. 1Uni-.es Stales eau noi avoilaoic. cut iigufe snouiC sc only cliffitly etc than 2.3. tUnites St.-te* sota r.ot available, but these arc rare causes of death in general population. mesothelioma, three: peritoneal mesothelioma, sev en; cancer of the colon, four; cancer of the rectum, one; cancer of the. stomach, three: cancer of the pancreas, two; cancer of buccal cavity and pharynx, two; cancer of blatider, one; cancer of undeter mined primary site, two; asbestosis, 15; cor pul monale, one; comary heart disease, IT; congestive heart failure, one; cerebral vascular lesion, two; aortic aneurysm, one; cirrhosis of the liver, three; bronchopneumonia, one: encephalopathy, ' one; acute pancreatitis, one: Wegener's granulomatosis, one; and accidental fall. one. Expected Dec!hi.--Tor purposes cf comparison, we wished to ascertain, how many of the 370 sub jects would have died curing the 52-mor.th period (Jan 1, 1963, to April 30, 1267) if their age-specific death rates had been exactly the same as for the general white male population of the United States. For this purpose, we made use oi the United States 1954 life table for white males: this provided the most stabh basis for comparison. It should be noted that for white males total death rates and death rates from respiratory cancer were slightly higher in the industrial states of New York and New Jersey than in the United States as a whole.*'" On the other hand, respiratory cancer death rates in white rnen aged 00 to 04 are reported to be a trifle lower than average among laborers, not elsewhere classified employed in construction work.* From the life table we determined for each of the 370 men the probability oi his dying within a pe riod of 52 months, considering his age on Jan 1, 1203, and assuming that the life table probability applied to him. Summing these probabilities for the 370 men yielded an estimate of the "expected" number of deaths under the null hypothesis that the age-specific death rates cf these asbestos work ers are the same as for United States white males in general. The computation indicated that 47.5 deaths would have been expected. Next, wo wished to estimate the expected num ber of deaths from each oi several cause.-'. For this, white males of various ages during the yea as reported by the National Center for Hear tistics. These percentages were then stand: for age according to the age distribution a of the 47.5 expected deaths. The results are in Table 3. Expected vs Observed Deaths.--As sno Table 3, there were 94 observed deaths ue, the 370 asbestos workers died) as comparec ' 47.5 deaths expected on the basis of the age-s death rates of all white males in the United . in 1964. Thus, there were 94 minus 47.5 * excess deaths. The excess deaths were due to chogenic carcinoma, mesothelioma oi the : and. peritoneum, asbestosis, and cancer o stomach, colon, and rectum. Cancer oj Lung, Pleura, end Trachea.--In lished mortality data for the United States . ing deaths each year from various causes b> sex, and race, the following diseases are comb cancer of the lung (including sarcoma of tne 1 cancer of the bronchus, cancer of the pleura cancer oi the trachea. For this group of cist there were 27 observed deaths and only 2.. peered deaths, a ratio of nearly 12 to 1. it is well known that, for the United S:a: a whole; all except a very few oi the death ported in the combined category are cue to i chogenic carcinoma. Thus, it may be assumed there were close to 2.3 expected `deaths irzrz cause as compared with 24 observed- deaths, a of over 10 to 1. -UesotAeifoma.--Ten oi the 24 observed d; were due to mesothelioma, three were cut pleural mesothelioma, and seven were due to ; tor.eai mesotheliomas. This is such a rare' cis that if the 370 subjects had been selected : random sample from the general population, would not have expected any of them to db mesothelioma within a period of 52 m.cntns. All three of the men who died of pi-tural rr. thelioma had a history of regular cigarette smox Oi the seven who died of peritoneal mesomelic one never smoked regularly, one smoked only r: and cigars, and five had a history oi regular c rette smoking. Cancer of Stomach, Color., and Rectum.--In earlier study of asbestos workers,' there were rr. deaths than expected from cancer oi the stem: coion, and rectum (2.4 expected, 2D observed), compared with a lotai of l.S expected deaths these causes, there were eight observed deaths this study, due to cancer of the following si: stomach, three; colon, four; and rectum, one. . though this bears out our earlier findings, the r.u ber of deaths from these causes was so smaii n we still refrain from drawing any conclusion this time. Asbestosis.--Asbestosis accounted for 15 of * 24 deaths. While it is not surprising ik.it w-.-at we made use o: the percentage distribution of from this disease occur among men c.xpuMii deaths by cause oi death among United States asbestos dust, attention must be caiicd to mu m 7 93 9 A 1^ JAMA. April . 1?CS Vef ZC`. r^ocSTQS EXPOSURE-- SEUKOFF ET AL 109 that these subjects were primarily insulation work Taois A.--Estimates Number of Lur; Cancgr Deatns E*oec!e<J Jo Occur During a Period of E2 Months per 10.0C0 Men Living at the Start of Period: by Age and by Smoking Habits* ers. YrTiile all of them were occupationally ex posed to asbestos dust, their degree of exposure was light as compared 'with the degree of ex posure of asbestos miners, processors, and weavers in earlier times. Bronchogenic Ccrcinoma.--Bronchogenic car. einoma accounted for 24 deaths while only about 2.3 were expected on the A*t. Tf tJJ. 1961} 35-39 40-44 45-49 5054 55-59 6064 63-69 7074 75-79 80-84 N#ur Smoked ReguUrly 0 2 2 -7 6 16 14 12 28 25 fiOC. Cir Only ...t 2 12 IS 31 32 32 53 32 Ctciortfl* Smoker*; 5 71 10 22 S3 71 97 100 100 148 1-9 * ojr 28 # to 103 * ... Current C.gjrttit Smoker*! 10-19 a 0*7 * 44 91 1S7 206 18S ** 2039 0*7 IS 39 69 117 190 305 288 341 ... 4041 Dy mmm 15 4690 185 256 3S0* 430* 329 ... *Sai*d uoon from a orotscstive stud/ *djus*rn*r* for US mortality *aenenct. ?ih9st* indicate rates om:ted far cuc?.*<t with no susitsts m tn.s study. Set Tjsit 2. sinciudts cigaret:* sr^?**'* wno a;*o sm^aes o>st or cigar. Men uih a mstory of only cigataUa smo**ng nave ngner lung cancer rztes tnan snown nera. ^Ratts odtsmed ty smootmng the oata. basis of general United States mortality data for divided into many five-year age groups, some of the white males. However, as previously mentioned, subgroups contained oniy a small number of men. evidence at hand suggests that there were propor In consequence, the lung cancer death rate was tionally somewhat more cigarette smokers among statistically unstable in some of the very small sub the 370 subjects than among white males in the groups. In three instances where the observed rate United States as a whole, age being taken into in a small subgroup appeared to be badly out of consideration. This might have partially accounted line, we arbitrarily made an adjustment to bring it for the high bronchogenic carcinoma death rate of more into line with adjacent figures in the table. the subjects. For this and other reasons we made These adjusted figures which are indicated with estimates of the expected number of bronchogenic symbols in Table 4 carry very little weight in the carcinoma deaths, the smoking habits of the men final calculation. All oi the rates were then ad being taken into consideration. This was done as justed as follows: follows: Lung cancer death rates in the United States Data are available on lung cancer deaths in re have risen steadily year by year and were higher lation to the sir.okir.2 habits of 440,000 men en in 196-1 than during the period I960 to 1964 as a rolled by American Cancer Society volunteers in whole. Furthermore, in the study described above, a prospective epidemiological study between Oc we avoided enrolling seriously ill people and. as of tober 1959 ana March 123C and traced through the cut-oil date for preparing the computer tape, Sept 30,1954. Causes of death were ascertained from we had not yet received death certificates for ail death certificates, hut whenever cancer was men of the men now known to have died during the tioned on a death certificate inquiry was made of specified period of time. For these reasons, lung the physician who signed the certificate. In case cancer death rates in the study population were of disagreement between the two sources of infor appreciably lower than those reported for white mation, the physician's statement was accepted. males in the United States in 1964. To compensate For the purpose at hand, we only made use of data for this, we raised the race of each individual smok covering the 52-mcnth period beginning on June 1. ing category so that the total lung cancer death 1960, and ending on Sept 30. 1964. The number of rate (disregarding smoking habits) in each five- lung cancer deaths occurring during the 52-mcnth year age group would be the same as chat oi all period was divided by the number of men alive at United States white males (based upon the 3964 the beginning of rise period. This was done by five- life table and the 1964 distribution of deaths by year age groups for men .in each of the following causes of death). The results of these computations smoking categories: (1) never smoked regularly are shown in Table 4. (It should be noted that (r.onsmokers and occasional smokers being com Table 4 shows oniy such rates as were required for bined); (2) history of regular pipe or cigar smok further calculations.) ing, past or present, but never smoked cigarettes The rates shown in Tabic 4 were then applied to regularly; (3) excigarette smokers (including those the number of asbestos workers shown in each oi who had smoked or currently smoked pipes or the corresponding internal cells of Table 2. This cigars); and (4) current regular cigarette smokers yielded an estimate of the number of lung cancer (including those who also had smoked or currently deaths expected to occur during a 52-month period smoked pipes or cigars). The last of these cate among the 370 asbestos workers classified by their gories was further divided by current number oi smoking habits. 3v "expected" number, we here cigarettes smoked per day: (4a) one to nine ciga mean an estimate of the number o: lung cancer rettes a day; (4b) 10 to 19 cigarettes a day: (4c) deaths which would have occurred under the null 20 to 39 cigarettes a day; and (4d) 40 or more hypothesis that asbestos workers do no: diiler from cigarettes a day. Sir.ce the men were divided into other men in respect to their lung cancer death raven groups by smoking habits and further sub rates, both age and smoking habits being taken JA.VA. April e. lSc-3 Voi 2M. No 2 A 794C 107 Table 5.--Observed and Expected 3rench.prer.ic Carcinoma Deaths by Smokinr Habits-* for 370 Ascestos Workers Smoking Habltv Nevir smoked regularly History o* pis*. Cigar imokinj only History ol regular cuarctte smokmjt Observed Dath 0 0 24 Cioetlee Deaths O.OS 0.13 2.98 Tout 24 3.16 `Based upon eats <n Tjrie 2 me Tapie 4. IIndudes cigarcRe tmektrt *no alio smoked pioa or ci*r. Table 6.--Expected and Observed Deaths Among 632 Ashes* tos Workers Exposed to Asbesto Dust 20 years or Longer Total deaths: all causes Expected Observed Total cancer: all sites Expected Observed Cancer of lung, trachea, pleura Expected Observed Cancer or stomach, colon, rectum Expected Observed Cancer all other sites combined Cxpected Observed Asbestesis Eipectcd Observed All ether causes Expected Observed 1943-1962 203.5 255 3&5 95 6.6 45 9.4 29 . 20.5 21 . 0 12 167 148 1963-1967 47.5 94 8.6 49 2J 27 ia 8 4.5 14 O 15 38.9 30 Total 1943=1967 251 349 4 SJ 144 8.9 72 11.2 37 25 35 O 27 20SJ 178 into consideration. The results are summarized in Table 5 which shows the expected and observed number ci lung cancer deaths in each of three smoking categories. Taking smoking habits as well as age into con sideration (Table 5) a total ci 3.2 bronchogenic carcinoma deaths were expected whereas taking only age into consideration 2.3 deaths were ex pected irom this cause (Table 3). Thus, perhaps one of the excess bronchogenic carcinoma deaths might be attributed to the tact that there appear to have been proportionally somewhat more ciga rette smokers among the 370 subjects than among men of the same ages in the general population. The following statements are based upon the data shown in Table 5. Twenty-four deaths irom bronchogenic carcinoma occurred among the 370 subjects compared with oniv 3.15 expected, a ratio of about 7.6 to 1. This is siighiiy hizher than iound in our earlier study which indicated a ratio of 6.S to 1 (not taking smoking habits into considera tion). It should be noted in this connection that the 370 subjects in this study had been exposed to asbestos dust somewhat longer titan the subjects of our previous study (the present 370 subjects are survivors as of Jan 1, 19G3, of subjects in the previous study). Of the subjects who never smoked regularly and those who smoked only pipes or cigars, none died of bronchogenic carcinoma whereas 0.1S of these mc-.n wi-io cxjvcteii lo die of iur.g cancer. This sug gests that exposure to asbestos dust docs not in crease tiic risk of bronchogenic cm cinema among 103 & i 7 94-1 men who never smoked cigarettes regularly. } ever, considering the small number of such sue in this study, we only conclude that exposu: asbestos dust does not greatly increase the r. bronchogenic carcinoma among men. who : smoked cigarettes regularly. T%venty-four of the men with a history of re: cigarette smoking died of bronchogenic carcir w'nereas only 2.9S were expected to die of it. a of S.05 to 1. From this it appears that exposu: asbestos dust greatly increases the risk of cancer among cigarette smokers. Now we may ask how greatly is the risk of l chogenic carcinoma increased bv the combinc-t fects of cigarette smoking and exposure to a?b-: dust To answer this question, we applied : shown in Table 4 for nonasbestos workers never smoked regularly to the number cf sub; with a history of regular cigarette smoking as sh in Table 2. This indicated that only 0.26 of subjects with a history of regular cigarette smo! would have been expected to die of bror.chor carcinoma if they had never smoked regulariy had never been occupationaily exposed to asbedust Since 24 of them actually died of this ca the ratio of observed to expected deaths is 92 (ie, 24 divided by 0.26 = 92). This'appears to dicate that cigarette smoking plus occupanc exposure to asbestos dust increases the risk bronchogenic carcinoma by a factor ir. the orde magnitude of 92 to 1. It should be r.pted that estimate does not take-current amount of cig?.n smoking into consideration. Comparison With Earlier Findings.--As explain we started with a cohort o: 632 asbestos insuiat workers, the entire membership of the union ice on Jan 1, 1943. V.*e have now traced each n through April 30, 1967. Table 6 show* the ebser and expected number of deaths for each of : periods (the first. 1943 to 1962, being previeu reported') and for the entire period. In respect respiratory cancer (lung, trachea, and pleura) z in respect to cancer of the stomach, colon. rectum, the findings in the two periods are in ch agreement. Comment The increased risk of neoplasia (mainly brcr.c: genic carcinoma and mesothelioma) among ir.su tio.n workers reported here should be evaluated the knowledge that these men have comparative light exposure as asbestos trades go. Primarily c ployed in construction work, many of the mater: they use contain little or no asbestos and crim have only 5% to 15%. Conditions of work va: these men often work outdoors unlike ::*:bc\s: operators in factory work. Comparatively few tiu exposure surveys have been mr.ci:? in this trade their results have generally been within the '< :: lion particles per cubic foot permitih.e ii.tiit= rcntrly accepted by the American C Governmental Industrial Hygiennu:.' " Nor ha JAMA. AprilS. )Cr:Z * Vr,l 't--jttirvijrr t.t AL in 'additional potentially carcinogenic substances been 40 years ago. Youngsters who start smoking now identified among the ocher materials used.'" have a much greater chance of having both ex Heavier or even lighter exposure may result in posures simultaneously. different degrees of risk of neoplasia. Heavy factory Significance of Findings for Asbestos Workers.-- \ exposure in the past has in some instances resulted The import of the data reported here seems clear. in considerable lung cancer risk." In others, para There is an extraordinary risk of developing and doxically, little lung cancer was seen because as- dying from lung cancer for asbestos workers who bestosis was so common and so severe as to cause smoke cigarettes regularly. In the group studied, death of the exposed workers before they could live the combination of asbestos exposure and cigarette long enough to develop lung cancer. Once exposure smoking increased the risk approximately 90 times v/as reduced by improved industrial hygiene prac compared with men who neither work with asbestos tices, early death from asbestosis sharply dimin nor smoke! ished and lung cancer became common.14 Of 283 asbestos workers who had a history of In any case, heavy exposure is not likely to be cigarette smoking, 7S died within a period of 52 the most important problem in the iuture. unless months whereas only 32.4 would have been ex there be sheer carelessness or unconcern. Raiher, pected to die within that length of time if their age light exposure, similar to that in insulation work, specific death rates had been the same as for the ..will be much more common, both in direct asbestos general white male population of the United States. working trades and as the result of indirect occupa Of the 7S deaths, 24 (31%) were due to broncho tional exposure, as in the construction and ship genic carcinoma. It is estimated that if these men building industries. had smoked cigarettes but had not beer, exposed to There is another type of "light exposure" which asbestos dust, only 2.9S would have died of bron may affect many more people than those industrial chogenic carcinoma within the same length of time. ly exposed. In the past several years, it has been If they had neither smoked nor been exposed to demonstrated that asbestos bodies can be found in asbestos dust, only 0.26 would have been expected the lungs of 259c to 50% of adults examined at to die of the disease within a period of 52 rf.onths. autopsy in large cities, such as Belfast. Northern Of ST asbestos workers who-never smoked ciga Ireland, Capetown, Republic of South Africa, rettes regularly, none died of lung cancer within the ivliami, Fla, Pittsburgh, and Montreal. This is 52-month period (although three died of asbestosis presumably due to "asbestos air pollution" by and one died of peritoneal mesothelioma). This fibers derived from industrial "spillover" 133 dust finding, being based upon the experience of only from construction sites or factory wastes) or from, S7 men. does net prove that exp-'sure to asbestos end-product use. Such community asbestos air dust has-no influence cn the risk of lung cancer pollution may be important since there is already among nonsmokers. However, it suggests that ex evidence that in certain circumstances, as living posure to asbestos dust docs not lead to an ex within half mile of an asbestos plant or in the tremely high risk of lung cancer among nonsmokers. household of an asbestos worker, intimate environ The conclusions are evident: mental contamination can be associated with some 1. Occupational exposun to asbestos dust should risk of mesothelioma/3 What is not now known is be reduced to as low a level as possible: but there whether the minimal amounts inhaled by the gen may be an irreducible minimum ievel if asbestos, a ? eral public carry a similar risk." very useful material, is to be used at all. Such Nor do we know whether inhalation of the very reduction in exposure will benefit asbestos workers small amounts of asbestos present in the air oi some of the future. However, we are also concerned with communities is associated with a special lung workers who have already been exposed at signifi cancer risk in cigarette smokers (or. conversely, cant levels for many years. Asbestos fibers will re whether cicr.tcUe smoking makes the inhalation of main in their tissues for the remainder oi their lives. very small amounts o: asbestos particularly hazard 2. All people incur a great increase in risk 0: lung ous). It will be important to ascertain whether such cancer it they smoke cigarettes: ior asbestos work .. ( cocarcinogenic or potentiating or precipitating rela ers the increase in risk is tremendous. Asbestos tionships exist because, with the rapid growth 0: workers who do not now smoke cigarettes should asbestos use (500.000 tons per year world produc never begin. Those who do smoke, should stop tion in 1930 has risen to over 4.000.000 tons per immediately. We may hope that the decrease in year now), it may be difficult for cigarette smokers risk which results from cessation of smoking among to avoid inhaling air contaminated with asbestos. the general public' will be the good fortune of the It may not he easy to unravel the interrelation asbestos workers as well. ships which might exist between community as Thi* invcaliiMfion wtis fcucporlcd by the Health fteae.iich Coun bestos air pollution and cigarette smoking. Both cil *j( the City u( New Yur*. asbestos exposure and cigarette smokinc have a References long-lapsed period between on.-et of exposure and 1. Or.irsr. !.: anil ILinminm!. F.C.: A *.% Kx- occurter.ee of rtw'pbsin. vet tor current smoke:s fvjMiiv <iul NVo:Cs:.. JA.\fA I> vJj-'J** *1 U*1 * these two exposures may not have begun simulta I.*/.: -Iami n.ir.'mi/ui. K.C.. I'.c* tvvr*r> fvx?o-*nrc to Asliv>lis an.I .Wu: Yn/ 7 **(*'*{ neously; there w;;.s much less .asbestos used 20 to t Mare.i l"i) i* i a. (7942y V.A. April 8. Vc-1 Z'C~l. Me 2 10a ^ 'Himmond. K.C.: "Sinolinf in Relation to the Dc.xth RMcsof 1 f>:0Men rd Women.'" in tlo.dr 'rim:^-tcri Study <>i Cancer er.i Olker Chronic Direases. lict):e*da. Mil: National Cancer ln*iilins. 1700. monorr.iph IP, j-p 12<-2&4. 4. etmnhir.g and Health. Report of the Ai!viorv Committee to the Nerjeon Cencral n: the i'onlic Health Rerxire. publication 1103. US Dept of Health. Etiuniuon. *r.tl Wrir.xrc. 19U4. 5. Hammsnd. E.C.. and Garr.nkel. L.: Chances in Cicarette Smoking 1P3P-1SC3. Amer J Public Health GSaCO--<" (Jan) 1968. 6. Vital Statistics o; the United States. J9r<0. part A. US Dept of Health. Education, anti Welfare, 1865. vol 2. 7. Death Petes From Malignant Neoplasms. 19601 Public Health Service, publication 1113. US Dept of Health. Education, and Welfare. 1563. 8. Mortality by Occupation and Cause o{ Death. Public Health Service. US Dept of Health. Education, and Welfare. Vital Sta tistics Division. Vital Statistics--Special Reports, 53:323 (Sept) 1963. 9. Vleixeher. \V.E et al: A Health Survey of Tipe-Coverinr 0|>rrations in Conviruriir.c Naval Vov<ls, J Jndustr Hvg Tone 28:9-16 (Jan) 1946. 10. Keane.* W.T,, and Zavon. MR.: Occupational Hazards of Pipe Insulators. Arch Kmiran Health 13:171-178 lAup) lS-5. 11. Doll. R.: Morulitv prom Lun; Cancer in Asbestos Worker*. Brit J Inaustr Med 12:81-96 (April) 1955. 12. Jacob. G. and An-pach. M.: Pulmonary Neoplasia Amonr Dresden Asbestos Workers. Ar.n NY Acad Sc 132:536-548 (Dee 31) 1965. 13. Ne^house. M.I-- and Thompson. H.: Mesothelioma of Pleura and Peritoneum Following Exposure to Asbestos in the London Area. Brit J Industr Med 22:2ul-29 (Oct) 1965. 14. SclikcS. et al: Asbestosi* and Neoplasia. Amer J Med 42:4S7-496 (April) 1967. Many, possibly most, of the words in the dictionary stand there as representatives of a whole family of forms. Not even the timidest of the linguistically timid will run to the dictionary for encouragement when, for instance, they want to refer to a spell of "hiccuping," provided they are certain that Webster does know "to hiccup." All the tense forms, the participles, the gerunds are assumed to be authorized by implication the moment the infinitive is known to exist. The plurals of nouns are similarly taken ior granted, and the forms of comparison and the adverbial forms of adjectives. This phenomenon is generally covered by the assertion that a dictionary is not a grammar and that each individual entry in a dictionary stands simultaneously for all its grammatically possible forms, f For details, consult your grammar.) But is a gerund a grammatical form? Or is it a suffix-derived noun? I am not really looking ior an answer. I ask those questions to suggest that the dividing line between grammatical form ana derived neoiogism is both hard to de fine and artificial. If I distinguish--among men--the "hunting'' nom the "hunted," I have done no more than form (grammatically) two nouns from two adjectives which are forms t grammatically) implied in the existence of "to hunt." But if "hunting" is implied, why not "hunter"? Why not "huntee" and "huntable" and "huntabilize"? Tne question of when a new word is a new word and when it is merely an "im plied" form of a conventional term is indeed more complex than is grossly 3ppa-ent. Take "jenairabilrty" r.s an example. Can I c'aim the word is implied in the existence of "hair," or must I assume the responsibility for having spawned a monster? Or take "unequivocably," which indeed was the starting point of all this rea soning and wondering, for it was sotted as a bold neoiogism in JAMA in the sentence, "Research at the Public Health Service Hospital at Lexington, Ky, has ur.equivocably proven that methadone has all of the euphoric properties of morpliine. ..." Now, clearly, the adverb "unequivocably" is grammatically implied in the ad jective "unequivocable." and this in turn is implied--grammatically of semi-grammaticnlly or otherwise--in "equivocable." If we grant further that formations in "-able" of "-ible" are likewise legitimate without special dispensation, we shall conclude that "unequivocably" is in no sense a bold departure since "to equivo cate" is a firmly established, standard English word. But there ,is a hitch and a flaw in the argument. "To equivocate" means "to use ambiguous language" and (by extension) "to render ambiguous." Hence, "equivocable" can only suggest the trait of "being apt or able to be made ambig uous," and Lhat, 1 fear, was not intended. Which means, by i nongrammaticnl) implication, that the discrepancy between the obviously intended meaning of "unequivocably" and its struciuully supported significance was the cause of the un pleasant jolt experienced by the spotting reader. PS.--It is of course possible, and even likely, that "uncquivocably" was just a typo for "equivocally." Alexander Code, ThD no .. A i 7943 JAMA. April 8. JSCS Vo! 2C4. No 2