Document r6dBdEamzDLmmJD0Z53oQGp8r

Chronic Occupational Exposure to Asbestos: More than Medical Effects? Allen H. Lebovits, PhD; Mary Byrne, MBA; Jonine Bernstein, MS ; and James J. Strain, MD One hundred and twenty-nine workers chronically exposed to asbestos were interviewed regarding their perceived health status and concerns, their health behaviors, particularly their smoking behavior, and their psychologic well-being. In con trast to a non-exposed comparison group of postal workers, asbestos workers exhibited significantly elevated levels of somatic concern (P < .03), and significantly lower levels of mental health functioning only when experiencing high levels of stress (P < .01). Despite feeling significantly more suscep tible to developing cancer (P < .0001), 34% of asbestos workers were cigarette smokers (compared to 32% of the postal group) and long-term mask usage was minimal. Asbes tos workers' increased sensitivity to stress and changes in health status along with the lack of adaptation of healthpromotive behaviors indicate the need for interventions to attend to the psychologic effects of increased risk status. The effects of inhaling asbestos fibers are time- and dose-related; continued exposure leads to various severe and debilitating diseases. Of those persons with substantial exposure, predictions are that 19% will die of lung cancer, 9% of asbestosis, 9% of gastrointestinal cancer, and 8% of mesothelioma.1 The question arises as to whether the increasing health consciousness witnessed in the last decade in the general population has also occurred among medical From SUNY Health Science Center at Brooklyn, Brooklyn, NY (Dr Lebovlta, Associate Professor, Departments of Anesthesiology and Psychiatry) and the Mount Sinai Hospital and School of Medicine, New York, NY Ms Byrne, Department of Psychiatry; Ms Bernstein, Department of BLomathematical Sciences; Dr StraiD, Professor, Clini cal Psychiatry and Director, Division of Consultation/Liaison Psychia try, Department of Psychiatry) Address correspondence to Department of Anesthesiology, Box 6, SUNY Health Science Center at Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203 (Dr Lebovits). 0096-1736/88/3001-0049S02.Q0/0 Copyright by American Occupational Medical Association risk groups, such as those who have had chronic occu pational exposure. Health-promotive behaviors, partic ularly smoking cessation, are singularly significant for asbestos-exposed individuals. Although the mechanism of asbestos-induced carcinogenesis is unclear, asbestos fibers may act as physical transporters of other envi ronmental carcinogens.*'3 Cell transformation by co carcinogens so commonly found in the blue collar envi ronment may be facilitated by asbestos. The asbestos worker who smokes has a risk of dying of bronchogenic carcinoma 53 times greater than that of the nonsmoking population, and 5 times greater than that of the smoking general population.4 Furthermore, cessation of smoking among asbestos workers has resulted in decreased risk of bronchogenic carcinoma.5'6 The question also arises regarding the mental health effects of chronic occupational exposure. Although as bestos is a major occupational and public health'prob lem, and there are many medical studies of cohorts of asbestos workers,1'4-10 minimal documentation is avail able regarding the psychologic sequelae of living with medical risk. Prior psychologic studies of actual or perceived hazardous exposures, such as at Three Mile Island,11-15 Love Canal,16'17 and with Michigan farmers exposed to polybrominated biphenyls,18'19 reflected rel atively recent exposures. Although investigators stud ied the chronic risk effect of in utero diethylstilbestrol exposure, women at risk were aware of their risk only shortly before the study.20 In sum, very little is known about the psychologic reaction to the knowledge that one has been continuously exposed to a hazardous sub stance. A study was designed to evaluate persons chronically exposed through their occupation to asbestos fiber and to compare them with a non-exposed group of blue collar workers with respect to (I) perceived health status, health concern, disease susceptibility, and health locus of control; (9) behavioral correlates of such exposure, Journal of Occupational Medicine/Volume 30 Mo. 1 /January 1988 49 -'garette smoking in particular; and (3) their psycho tic well-being and mood states. Methods Study Participants One hundred and twenty-nine asbestos workers from the New York metropolitan area, members of the Inter national Association of Heat and Frost Insulators and Asbestos Workers, were interviewed. Criteria for inclu sion were a minimum of 20 years in the asbestos insu lation trade, and continuous "field" exposure into the past 5 years (to exclude those who worked exclusively in an office). The cohort studied participated in medical surveillance examinations over the last 20 years and its medical risk has been well documented.7 Due to the lack of standardized measures to assess the psychologic status of blue collar workers, a compar ison group was utilized to serve as a "normative" stand ard. US Postal Service workers were chosen because as a group they had not knowingly been exposed to any hazardous substance, were demographically similar to asbestos workers, and performed manual labor. One hundred postal workers who had worked for the postal service a minimum of 20 years were entered onto study. (Six postal workers were excluded from this analysis because of a history of direct occupational asbestos losure on jobs outside the postal service.) Recogniz the inherent work characteristic differences between the asbestos and postal groups, statistical covariates were implemented in the analyses, to control for group differences. Asbestos worker participants were recruited from more than 600 cohort records of the Environmental Science Laboratory of The Mount Sinai School of Medi cine, whereas postal workers were recruited from a pool of more than 550 potential study-eligible participants. Asbestos worker participants represent 49% and postal worker participants represent 32% of those successfully contacted who met the inclusion criteria for this study (Table 1). Both groups were exclusively male and were similar demographically with regard to marital status, level of education, number of years in the trade, and physical iealth status (as measured by the Karnofsky Patient Performance Scale)21 (Table 2). Asbestos workers were, lowever, significantly younger, had a significantly ower Hollingshead socioeconomic status score (A.B. Hollingshead, unpublished data), and also differed in ace and religion. These group demographic differences lid not relate either statistically or clinically to the lutcome measures. assessment Measures . tandardized measures with published reliability and alidity were administered. To evaluate perceived .ealth status and concern, two scales of the Current and 'ast Psychopathology Scales (CAPPS) were used, the 0 TABLE 1 Sample Recruitment Asbestos Workers Those successfully contacted who met eligibility criteria for study Declined participation Interview not scheduled by end of study Participated 262 76 (29%) 57 (22%) 129 (49%) Postal Workers 308 151 (49%) 57 (19%) 100 (32%) TABLE 2 Demographics Asbestos Workers Age Hollingshead SES score Years in trade Karnofsky physical health status rating (100 = maximum) Sex (% male) Race (% white) Religion (% Catholic) Married, % Education level, % >High school >9th grade <9th grade 51.1 31.1 27.7 88.4 100 100 78 91 22 49 29 ' NS, not significant. Postal Workers 55.9 33.2 27.9 88.4 100 91 48 88 16 53 31 <.0001 <.01 NS* NS NS <01 <.0001 NS NS Current and Past Somatic Concern Scales (C-SC, PSC).22 The Multidimensional Health Locus of Control Scale evaluated perceptions of internal and external control of health,23 and questions evaluating perceived health status and disease susceptibility were also asked.24 Present and past health behaviors were as sessed, particularly smoking behavior,25 alcohol con sumption,22 usage of masks, and physician visits. Two other scales of the CAPPS were administered, the Cur rent and Past Depression and Anxiety Scales (C-DA, F DA), as well as CAPPS-derived present and past global distress scores, to assess overall level of psychological distress. The Global Assessment Scale (GAS) was also used to determine overall level of mental health func tioning.26 In addition to these measures, the Sixteen Personality Factor Questionnaire (16PF)27 was used as a measure of between-group trait comparability, and the Recent Life Changes Questionnaire (RLCQ)26 was given to compare group differences in level of stress prior to the evaluation of present distress. A specially devised project questionnaire evaluated the specific pa rameters of this study: demographics, occupational and exposure histories, adoption of health-promotive behav iors, and acquisition of risk information. Reliability and Participant Refuser Studies Because some instruments used were interviewer rated measures, inter-rater reliability was determined for the two interviewers. To control for bias, an inde pendent rater "blind" to the overall and specific study Chronic Exposure to Asbestos/Lebovits et ai obj< The ind rat t wit the stu vai she ing da; Sta dif he PS. (t) po di: Vs ^ pc lo. CO in be ui er g* a? S'si ti v; S ti cc P*' o' 0 C r e % \ c objectives assigned ratings to audiotaped interviews. The resultant intra-class correlation coefficients were indicative of reliable ratings with a minimization of rater subjectivity. A participant-refuser comparison was undertaken with the asbestos worker study participants to evaluate the presence of volunteer bias. Comparability of the study participants to the first 61 study refusers on five variables available from existing medical cohort data showed no significant differences regarding age, smok ing history, age started to smoke, cigarettes smoked per day, and year started in the insulation trade. Statistical Analyses The analytic premise for this study was to evaluate differences in perceived health status and concern, health behaviors and awareness, and overall level of psychological distress between the experimental group (the asbestos workers) and the comparison group (the postal workers). To ascertain that any obtained group difference was due to the presence or absence of chronic hazardous exposure, it was important to control for possible sources of group differences in present psycho logic status other than asbestos exposure. Analysis of covariance was used with three criteria used for select ing the appropriate covariates: (1) Clinical relevance between the covariate variables and the outcome meas ures, such that the covariates could theoretically influ ence the outcome measures. For example, between group trait factors evaluated through the 16PF, such as neuroticism or anxiety, could influence between group differences in current mood state levels of depres sion and anxiety. (2) A significant correlational rela tionship to the dependent outcome psychologic status variables. (3) A significant difference between the groups on the variable. Statistical calculations were performed using the Sta-. tistical Analysis System software package on an IBM computer system. Descriptive statistics, correlation coefficients, and frequency tables were calculated. The "REG" procedure was used for the analysis of covari ance to determine between group differences regarding perceived health status and concern and overall levels of psychologic distress. However, the basic assumptions of analysis of covariance could not be satisfied for the GAS, C-DA, and P-DA scores because of resultant sig nificant interactional effects. Results for these scales are therefore evaluated with respect to predicted scores given the extreme minimum and maximum covariate values. The coefficients of the regression equations were derived from a stepwise regression among the co variates. ' Results Perceived Health Status and Concern Asbestos workers were aware of their risk status, having learned of the dangers of asbestos, on the aver age, 18 years prior to the interview. More specific risk information, such as the synergistic relationship be tween smoking and asbestos, was acquired, on the av erage, 3 years later. Only 4% of the asbestos workers never learned of this synergistic relationship. Postal workers, on the other hand, learned of the dangers of asbestos, on the average, 6 years prior to the interview and 97% never learned about the smoking/asbestos interaction. The two groups did not differ in their level of physical health status. Similarly, asbestos workers did not per ceive their health status differently than did postal workers. When asked to rate their present health status on a five-point scale ranging from "very poor" (rating = 1) to "very good" (rating = 5), asbestos workers and postal workers averaged mean ratings of 4.14 and 3.96, respectively. Perceived health status appeared to reflect accurately the actual physical health status: perceived health sta tus ratings correlated positively and significantly with the Karnofsky ratings of actual physical health status for both asbestos workers (r = .33, P < .002) and postal workers (r = .24, P < .02). The correlations between physical health status (actual and perceived), and so matic concern, depression/anxiety, psychological dis tress, and current mental health functioning are de scribed (Table 3). Although the actual correlation coef ficients are of a low order (.40 and lower), they were statistically significant for the asbestos workers, but not for the postal workers in three out of four correlations between physical health status and psychological out come measures, and in all four of the correlations be tween perceived health status and psychological out come measures. This is indicative of a much stronger relationship between health (actual and perceived) and psychologic status for the asbestos workers than for the postal workers. An analysis of covariance performed on the Current Somatic Concern Scale of the CAPPS, after adjusting for the significant covariates of neuroticism (as meas ured by the 16PF) and past year stressful life events (as measured by the RLCQ,), showed that asbestos work ers were significantly more concerned about their cur rent health than postal workers were and exhibited greater somatic expression of this concern (P < .03). There were, however, no statistically significant differ ences between groups on past concern about health and its somatic expression after adjusting for the relevant covariates, nor on the subscales of the Multidimensional Health Locus of Control Scale. When asked to rate their chances for getting cancer and coronary heart disease, asbestos workers believed they were significantly more likely to develop cancer than did postal workers (x2 -- 30.54, P < .0001). Fiftynine percent of asbestos workers believed their chances were likely for developing cancer compared to 26% of postal workers. Asbestos workers also believed them selves to be significantly more likely to develop cancer than coronary heart disease, whereas postal workers did not share this increased susceptibility to cancer (x2 = 20.90, P< .001). Journal of Occupational Medicine/Volume 30 No, 1/January 1938 51 TABLE 3 Correlations between Health Status and Psychological Outcome Measures (Pearson Correlation Coefficients)* Actual Physical Health Status (Karnofsky) Asbestos Postal Workers Workers Perceived Physical Health Status Asbestos Postal Workers Workers Current depression/ anxiety (C-DA) Current somatic con cern (C-SC) Present distress (CAPPS) Global mental health (GAS) --.22f -.40* -.25t .14 -.08 -.15 -.08 24 -.27* -.24* -.28* .29* -.03 -.18 -.11 .03 * Direction of measures are as follows: Kamofsky: 0 to 100, 100 best rating of physical health; Perceived: 1 to 5, 5 = best rating of physical health; C-DA, C-SC, and CAPPS: 1 to 6, 6 = most psycho pathology; GAS: 0 to 100,100 = best rating of mental health. tP<-01. *P<.001. P < .05. Health Behaviors Despite the fact that smoking cessation is the single most effective health-promotive behavior that asbestos workers can adopt, there were no significant differences in smoking prevalence or amount smoked between the groups (Table 4). Thirty-four percent of asbestos work ers were presently smoking, and another 44% of asbes tos workers had smoked in the past. Asbestos workers were rated as having significantly higher levels of current and past alcohol abuse on the CAPPS and also reported being drunk more frequently than postal workers. Although not significantly differ ent, 17% of asbestos workers reported a history of alcohol dependence, compared with 12% of postal work ers. , The median percentage of time masks were used at work over all the years was 10%. While on the job, only 8% of asbestos workers wore masks for more than 50% of the time. Although asbestos workers went to an average of 4.4 medical surveillance examinations since acquisition of risk information, 44% of the asbestos group, however, never went to their primary care phy sician for regular physical examinations (without symp toms) after learning of increased risk. Overall Level of Psychological Distress As noted above, significant covariate interactional effects for the GAS, C-DA, and P-DA scales necessitated evaluating predicted scores for these dependent vari ables given minimum and maximum covariate values. When stress (as reported on the RLCQ) assumed a maximal value, asbestos workers had a significantly lower level of mental health functioning (GAS) than postal workers did. Under conditions of maximum neuroticism (16PF), postal workers had a significantly lower level of mental health functioning than asbestos 52 Cigarette smoking Present, % Past, % Never, % Pack years (mean) TABLE 4 Health 8ehavicrs Asbestos Workers Postal Workers P 34 32 NS* 44 40 NS 22 28 NS 36 33 NS Alcohol abuse Current (CAPPS rating)* Past (CAPPS rating)* Drunk frequency* History of alcohol dependence,% 1.38 2.02 4.75 17 1.19 1.70 5.79 12 <.03 <.05 <.0001 NS Other Time used masks (median), % Never went to primary care physician for physical, % 10 44 * NS, not significant. 11 = none, 6 =* extreme. * 1 = once a week, 6 = never. -- 49 -- NS workers did (Table 5). This significant interaction effect between the covariates and the dependent variable also occurred when current and past depression/anxiety was evaluated. Under maximal conditions of trait anxiety (16PF), asbestos workers had significantly more psy chopathology on the C-DA scale of the CAPPS than postal workers did. Analysis of covariance with the P DA scale of the CAPPS revealed that postal workers exhibited significantly elevated scores except under the condition of maximum trait anxiety where asbestos workers had significantly higher levels of past depres sion and anxiety than postal workers did. The groups, however, did not differ in present and past distress global scores derived from the CAPPS. Similarly, there were no significant differences in. inci dence of treatment for psychopathology. Only 11% of asbestos workers and 19% of postal workers had ever visited a mental health professional. Discussion Several important findings and implications emerge from this study. Asbestos workers exhibited an elevated level of current somatic concern relative to the compar ison group. Although their actual health status and their perception of their health status did not differ from those of the postal workers, their increased somatic concern may be reflective of their (correctly) perceived increased susceptibility to cancer. This health concern appeared to be firmly related to actual physical health status, such that deteriorating health led to increasing somatic concern, increasing levels of mood state dis turbance, and deteriorating mental health functioning. The fact that this correlational relationship occurred only within the medical risk group may indicate that living with the "time bomb" of chronic asbestos expo sure leads to a heightened sensitivity to changes in Chronic Exposure to Asbestos/Lebovits et al TABLE 5 Significant interactional Effects of Analyses of Covariance' Covariate Levels Predicted Scores Neurotieism Life Events Anxiety Asbestos Postal SE P < Workers Workers Global assessment scale Past depression/anxiety score Current depression/anxiety score Min Min Max Max Min Min Max Max Min Min Min Min Max Max Max Max Min Max Min Max Min Min Max Max Min Min Max Max Min Max Min Max Min Max Min Max Min Max Min Max 84.43 70.03 74.67 60.27 1.16 1.99 1.08 1.91 1.06 1.85 1.54 2.33 0.85 1.64 . 1.33 2.12 83.31 83.31 68.47 68.47 1.23 1.23 2.13 2.13 1.07 1.07 1.55 1.55 1.56 1.56 2.04 2.04 0.51 3.69 2.81 2.94 0.02 0.30 0.33 0.10 0.02 0.28 0.02 0.28 0.31 0.21 0.31 0.21 .05 .01 .05 .01 .001 .02 .01 .05 NSt .01 NS .01 .05 NS .05 NS 'Regression equations are given. "Group" values are 1 for asbestos workers, 0 for postal workers. GAS score = 86.57 -- 1.81(neuroticism)+0.62(neuroticismXgroup)-0.03(life events)(group); past depression/anxiety score = 1.03 - 0.12(neurotici$mXgroup)+0.11 (neurotici$m)+0.10(anxietyXgroup); current depression/anxiety score = 0.96 + 0.06(neuroticism)+0.001(lifeevents)+0.095(anxietyXgroup)0.085(neurotici$mXgroup). t NS, not significant. physical health status. In addition, the elevated level of current somatic concern exhibited by the exposed group did not occur with past somatic concern. This may reflect the augmented increase in medical risk that occurs after 20 years of exposure,1 a point in time when the long-term cumulative asbestos dosage can set the time bomb off. Although the threat of cancer was consciously ac knowledged at a cognitive level, it was not reflected in the behavioral arena. Despite being well informed of their risk and feeling significantly more susceptible to developing cancer, health-promotive behaviors such as smoking cessation, long-term use of masks, and physi cian visits were not appreciably affected. Nearly one out of three asbestos workers continuing to smoke is a particularly disturbing finding, considering the current epidemiologic data that suggests that smoking cessation is an even more effective health-promotive behavior than leaving the trade. Although cessation of asbestos exposure prevents an increase in cumulative asbestos dosage, there is no evidence that an asbestos worker who leaves the trade actually reverses his risk of lung cancer, as does the asbestos worker who stops smok ing.5-6 Smoking, for an asbestos worker, indeed adds insult to injury. The findings of increased prevalence of alcoholism among asbestos workers is also of concern, considering the potential carcinogenicity of alcohol abuse and also in light of a recent report29 that alcohol ism may increase the incidence of pulmonary disease by enhancing the effects of asbestos. Asbestos workers, therefore, require psychosocial interventions to promote health behaviors which can reduce and even reverse their risk; few segments of the population could benefit more from such an intervention. . Although overall levels of psychological distress and use of mental health services did not strikingly differ entiate the occupationally exposed workers from a non- exposed work force, certain mediating influences were striking. When stressful life events were maximized, asbestos workers had a significantly lower level of men tal health functioning. Living with the time bomb of chronic asbestos exposure may therefore contribute to an over-reactivity to stress, as evidenced by the rela tionship between stressful life events and mental health for the exposed group, but not for the comparison group. The cumulative effects of chronic awareness of risk status may be to overtax the asbestos worker such that his "threshold of endurance"30 to daily stress is lowered. A recent study of the long-term psychologic effects of diethylstilbestrol exposure has similarly found an in creased vulnerability to stress among diethylstilbestrol mothers.31 ^ The lack of present and past excess psychologic dis tress and the absence of group differences regarding perceived control of health on the part of the exposed group is surprising. This may be explained, however, by reports of use of denial as a coping strategy when faced with a long-term stress or trauma.32 Denial may, there fore, be a common coping mechanism to chronic occu pational exposures. Although it may serve the function of reducing psychologic distress, it apparently also has the maladaptive function of minimizing optimal adap tation of health-promotive behaviors. Li et al33 similarly found that, although shipyard workers were well aware of the health risks of smoking, their behavior reflected denial of that risk. For exposed workers, perceived or actual deterioration of physical health status may inter fere with the denial process, resulting in increasing levels of psychologic distress. . The increasingly prevalent worker "right to know" movement is an important first step in the necessary dissemination of risk information. Further research Journal of Occupational iVledicine/Volume 30 No. 1/January 1988 53 must be conducted to supplant traditional educational campaigns with more specifically designed interven tions. Research on the efficacy of altering Type A be havior in men at increased cardiovascular risk has demonstrated the importance of the specificity of the intervention.34 Structured interventions such as smok ing cessation classes or on-the-job behavioral interven tion strategies, as found in workplace health promotion programs, are essential. Stress management techniques may be particularly helpful for chronically exposed workers to help minimize their increased vulnerability to daily stress. Long-term asbestos workers are concerned about their health, feel very vulnerable to cancer, and exhibit distress reactions as a result of specific mediating influ ences, such as daily stress levels or personality traits. Living with the time bomb of chronic asbestos exposure leads to a greater reactivity to stress and a heightened sensitivity to changes in physical health status. The effects of long-term asbestos exposure are, therefore, not exclusively medical. The constant threat of cancer vulnerability exacts its psychologic toll as well. Acknowledgments This research was supported by National Institute of Environment Health Sciences Grant 5R01ES02578 awarded to Dr Lebovits. We are indebted to Drs Irving Selikoff, James Holland, Philippe Chahinian, John Thornton, Steve Solomon, and to Judith Headier, for their assistance to the project. Computer scoring was performed by Dr John Nee of the Psychiatric Institute of Columbia University. Special ap preciation to Dr Daniel Leight and Mr Don Kelpinski of the US Postal Service, Dr Cynthia Lewin for her editorial assistance, and Marlaine Larosiliere for her preparation of the manuscript. References 1. Selikoff IJ, Hammond EC, Seidman H: Mortality experience of insulation workers in the United States and Canada, 1943-1976. Ann NY Acad Sci 1979;330:91-116. 2. Craighead J, Mossman B: The pathogenesis of asbestos-associ ated diseases. N Engl J Med 1981;306:1446-1455. 3. 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New York, Guilford Press, 1985, pp 145-205. 31. Gutterman EM, Ehrhardt AA, Markowitz JS, et al: Vulnera bility to stress among women with in utero diethylstilbestrol (DES)exposed daughters. J Human Stress 1985;11:103-110. 32. Breznitz S (ed): Denial of Stress. New York, International University Press, 1983. . 33. Li VC, Kim YJ, Terry PB, Cuthie JC, et al: Behavioral, attitudinal, and physiologic characteristics of smoking and nonsmoking asbestos-exposed shipyard workers. J Occup Med 1983;25:864-870. 34. Roskies E, Seraganian P, Oseasohn R, et al: The Montreal Type A intervention project: Major findings. Health Psychol 1986;5:45-69. 1i! 1 f I i i i 54 Chronic Exposure to Asbestos/Lebovits et al