Document reDvQ0KOnLq1Op3rmvrx01NN0

PLAINTIFF'S EXHIBIT 106 Asbestos Exposure, Smoking, and Neoplasia Iriling ]. Selikoff, MD: E. Cttyler Hammond, St:D; and Jacob Chttrg, i\lD . 'V.l' i - T% Yd Asbestos insulation workers, as a group, have a high due to chance, the number of such deaths bci:.r.'. risk of dying of bronchogenic carcinoma (about seven of small. During the latter part of the study, we eight times.exoected). We have observed 370 such work tained information on the smoking habits of mo;: | men from Jan 1, 1963 to April 30, 1967. Our findings of the survivors, but we could not obtain reliable;-.! indicate that asbestos exposure_a|one. is_jp.ot,the entire information on the smoking habits of those who* explanation. Of 87 noncigarette smokers, none _died_of had died at an earlier date. Therefore, we could." bronchogenic carcinoma. Of 283 workmen with a history . not at that time investigate death rates in rei3--: q/,.regular_cigarette.smoking, _24..died of.bronchogeniAA. tion to smoking habits and exposure to ashosuv:, carcinoma, although only_three were expected to die, of N dust which were considered both separately and-.- '.his_d.isea.se, Calculations suggest that asbestos workers jointly. who smoke,have--about. 92 limes~the~risk"6f "dying~6f bronchogenic carcinoma as men who neither work with asbestos nor smoke cigarettes. We conclude that"asbestos Th.erejs abundant evidence that cigarette sraos--; ing. leads, to a high rate of death from lung cancerj in_the_absenee of occupational exposure to asbestos - exposure should be minimized, that asbestos workers who dust.1-4 Qur .findings. c^J.lined .above suggested Jbmc. do not smoke should never start, and that those now did'not prove) .that-eji'posure. texasbestos dust mays* ' smoking should stop immediately. lead to a high rate of death from lung, cancer in-y the^alisfince of cigarette smoking. If tbe-iaiiar tei-. rn 1964, we reported on deaths occurring between _ 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-theea. men had-bean occupationally-exposed to asbestos dust for many years. Their death rate from lung cancer was found to be 6.8 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 of peri so, then the combined effect of both types of-ei-s posure might or might not be e<]ual to or greater.-?.- than the sum of the two effects. Qn the other hand,,;-, it was .possible that exposure tn asbestos dust. m-<v creases_the risk of lung cancer among cigarette;- smokers but does not Lad to lung cancer amor.^y iipnsmolccrs. The present study was undc-ilaken primariI/; to investigate! these possibilities. In addition, wc.-.* wished to obtain more information on the occur--': rence of mesolhelioma and gastrointestinal cancer,; among asbestos workers. d toneal mesothelioma. This was of interest since y- mesothelioma is a very rare disease in the general population but is reported to be associated with exposure to asbestos dust.1 In addition, their death ^ rate from cancer.of the stomach, colon, and rectum '^`V.was higher than expected; but this may have been -- - ; ------- - ; ' From the D*parhm*nt of Community Motlieme. Mount Sinni -hool of M*tltcmc (Ors >:likofI and Cluirm, and the Depart- ment of Epulemioloiry and Statistics. American Cancer Society Material ,4 From records of New York Lora, ill and Newark/..NJ, Local 32 of the International Association ot-s Heat and Frost Insulators arid Asbestos Worker;,?* a list was made of every man who was a members? of either one of these locals-on D'-c 31. 1942, or# who joined between that date and Dec 31, 1962.^No one was omitted regardless of his subac-iuenL; t Or. fcfammomi). New York. Head htiforn a joint uwetini; of the* Section nn Jhsrn*r< of the `Chest with the Section on f'rrvcntiv# Medicine nml the American College of Chr*t Physician* at the 1Ifith minimi convention uf the American Mcdtnil Aasociatton, Atlnntir* City, N.r, .lime ID, 1DG7. Hc|>rtnt rcrpiefcl* to Mount Sinai School of Mwtirtne. 100th Street in/i Fifth Avin** N<*u York * | r work history. Personnel data from union records indicated that-*? of the 632 on the union rolls, on .Jan 1. 1943. 33fL of the tnen had first- bi.-.-n occupationally expuaedy to asbestos dit-r pilo-- : .-I .o i-1-'1 -vd-* 06290 448059 i. ar 3; ''4 ~.e .A'*. -.fir ...hV. -ii S -*3$ '.yj* i u-V ** h &vk> v-4b-. W-A , ASBESTOS EXPOSUHE-SEUKOFF CT AL 107 293 men had first been ex posed between the be- Table 1---Sublets Classifi-d by Age as of Jan 1, 1963. and by Ycd.-s From First Occupatir-n Exposure to Asbestos Dust up to Jan 1. 1963 lining of 1923 and. the end of 1942. All of these men were successfully traced through Dec- 31, 1962, 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 rr 35-39 40-44 45 49 50-S4 55-59 60-64 65*69 70*74 75-79 80*84 Total No. of Subject* 2 13 32 109 60 42 49 38 21 4 20-24 2 12 . 17 ... ... ... ... 4.. ... No. of Ytars Sine* Firt Eipoturo (o Abi>.tj, 25-29 . .. I 2 1 i l ... 4*. 30-34 13 80 16 3 l ... ... 35-39 73 34 11 10 3 ... ... 40-44 .. 3 19 ia 12 l l 4'Mi 1 b is 6 s i SG + 2 17 IS 2 No. of C4tht. 02 Mo l 2 13 11 16 17 13 8 3 first exposure to asbestos Total 370 31 6 113 86 59 39 36 94 dust and 255 occurred after the 20th anniver sary. Thus, of the 632 Table 2.--Subjects Classified by Age and by Smoking Habits on or about Jan 1, 1963 men. 370 were still living on Jan 1, 1963. These 370 men were the subjects of the pres ent investigation. Table 1 shows their age distribu tion as of Jan 1, 1963, and the lapsed time from first exposure up to that date. All 'of them have been traced, and 94 of A, Yr 35*39 40*44 43*49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 Total Total No. 2 13 32 109 60 42 49 38 21 4 ---- 370 Never Smoked Regularly i 2 2 12 6 7 6 7 3 2 -- 48 p00. Cigar Only .. 4. 1 6 5 4 a 7 7 1 ---- 39 cigarcRc Smoker** 1 2 5 26 16 IS 17 12 6 1 ---M 101 Current CSftarettf Smoker** 1-9 a Oay .. . 3 t . -- 10-19 a Day .,. ... 4. 5 3 4 4 1 ... -- 17 20*39 a Oay 5 12 33 20 n 9 4 3 ... 97 40+ a Oay 4 * 12 24 10 4 S 3 1 .. * 63 them were found to have * Include* cigarette emoMtrs who also smoked pipes or cigar*. 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 clay, 17 smoked 10 to 19 Beginning in October 1962, we made arrange cigarettes a day, 97 sqeked 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 o-` a large num include chest x-ray films as well as physical ex ber of men selected from the general population.' amination and cover past and present smoking There were_proportiona 11y 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 338 (91.4) of the men at least once consideration. and have repeatedly examined most of those who Causes of Death.--A copy of the death certificate are still living. was obtained for each of the 94 deaths. In addi Information on smoking habits was obtained by tion, we examined hospital records, postmortem personal interview with the 333 men who were ex findings (41 cases), ns well as the surgical and amined. Of 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 not alter *ell) ascertained the smoking habits of 18 men, the picture as much as might have been expected an,l family members supplied the information on since there were several compensating errors. For remaining three men. This accounts for all of example, in one instance the death certificate in ^6 370 men. Table 2 shows their smoking habits dicated bronchogenic carcinoma as the cause of n or about Jan 1, 1963, the men being classified death while a review of the histologic specimen y their ages on that date, even though some showed that death was due to pleural mesothe changed their smoking habits between 1963 and lioma; hut in another instance exactly the reverse was found. Likewise, review in one instance re QL the 370 men. 48 never smoked regularly, 39 sulted in changing the reported cause of death smoked or find smoked pipes or cigars but never from bronchogenic carcinoma to cancer of the ~2k.9lLifinxetesjregula rjy, _arid *283' had"smbkcd stomach with metastasis to the lungs while review ilgarettes regularly. Some of those~wUh~hisEory~6f in another instance resulted in exactly the oposite c'"arette smoking also smoked pipes or rig,ire. Of change. TheJM. deaths were ascribed ?f* d >- fni'ew- 283 with a history of regular t i:;in'ff* -wirinp jjKT 06291 448060 * < : f 108 ASBESTOS EXPOSURE--SfiLIKOFF ET AL 1 ,,/ Table 3.--Observed and Expected Number of Deaths Among 370 Asbestos Workers During the 52-Month Period white males of various ages during the year piqU as reported by the National Center for Health sJ-j Ciutt ol OmUi Total, cancer (all vtei) Cancer of 'unit, pleura. bronchus, and trachea 8ronchoacntC carcinoma Pleural mesothelioma Peritoneal mesothelioma Cancer of stomach Cancer of colon and rectum Cancer of ail other sites combined Abtou Obierv Oe*tt._ 49 n 24 3 7 3 S 7 15 C'oected Ceatns* 9.S 2.3 ? t t 0.6 12 4s tistics. These percentages were then standardized'* for age according to the age distribution at t:r; - ^ of the 47.5 expected deaths. The results are shr,v.vin Table 3. Expected us Observed Deaths.--As shown Table 3, there were 94 observed deaths (ie, 9| 0; the 370 asbestos workers died) as compared \ 47.5 deaths expected on the basis of the age-spccii];.^ death rates of all white males in the United Statev? Heart and eireuiatory disease including stroke All other causes of death 22 28.S in 1964. Thus, there were 94 minus 47.5 = .i6.j.'n a 10.4 excess deallis. The excess deaths were due to Ikoo-4 Total, all causes 94 4 7.5 chogenic carcinoma, tncsothelio.ma of the pleura-.\ "B.j.d uoon US mortality dita disregarding smoking habits, and peritoneum, nsbestosis, and cancer of rumted Stata* data not available, but ftgur. should at only slightly lis than 2.3. tUnited States data not availabl*. but the*. art rara cause* at death in general population. stomach, coion, and rectum. ................. Cancer of Lung, Pleura, and Trachea.--In pub-TS lished mortality data tor the United States sr.ow-.-j mesothelioma, three; p_eritoneal mesothelioma, sev-^ ing deaths each year from various causes by oge,-.- en;-cancer. of.bhe colon, four;._cancer_oF.the.rectum, sex, and race, the following diseases are combined:.-, one; cancer of the stomach, three; cancer of_the cancer of the lung (including sarcoma of (he lung);"-* p.ancreas~t'\vo; cancer ofbiiccal_cavity andjpharynx, cancer of the bronchus, cancer of the pleura, ar.c! two; caricer~of"bladder, one; cancer of undeter- cancer of the trachea. For._this..group of diseases,;.; mine.d.^rimarsTte,"two; asbiitosis, 15; cor pul there .were 27 observed deaths and only 2.3 ez-'h; monale. one; comary~heart"disease,_17j._congestive / pec*AJ* ted" deAAatkhUsA, aA 'rHaA kti.oA AoCf nearly*,tA h! # 11 ^ ^ '* 1 heait.failure,__one; .cerebral vascularJesion^ two' [t is well known chat, for the Uuun,itedu uStuantecs aortic aneurysm, one; cirrhosis of the liver, three; / Na whole, all except a very few of the deaths re bronchopneumonia, one; encephalopathy, one; ported in the combined category are clue to bron-" acute pancreatitis, drie;"Wegener,s granulomatosis, chogenic carcinoma. Thus, it may be assumed that i one; and accidental fall, one. there were close to 2.3 expected deaths from this ~ExpecietFDeathf.--For* purposes of comparison, cause arcompared with 24 observed deaths, a ratio we wished to ascertain how many of the 370 sub of over 10 to 1. jects would have died during the 52-month period M.eothelioma.--Sen of the^94 observed deaths (Jan 1, 1963, to April 30, 1967) if their age-specific were due .tO'-me*ethe!iomar -three, .were .due. Jo ; death rates had been exactly the same as for the pleural mesothelioma, and seven were due to peri--Vi general white male population of the United States. toneal mesotheliomas. This is such a rare disease 7. For this purpose, we made use of the United States that if the 370 subjects had been selected as a - 1964 life table for white males; this provided the random sample from the general population, one ; most stable basis for comparison. It should he wo.uld not have expected any of them to die of noted that for white males total death rates and mesothelioma within a period of 52 mouths. ' death rates from respiratory cancer were slightly AH. three of the men who died of pleural meso higher in the industrial states of New York and thelioma had a history of regular cigarette smoking. - j New Jersey than .in the United States as a whole.'''1 Of the seven who, died of peritoneal mesothelioma, On the other hand, respiratory cancer death rates in one never smoked regularly, one smoked only pipes white men aged 20 to 64 arc reported to be a trifle and.cigars, and five had a history of regular ciga lower than average among laborers, not elsewhere rette smoking. classified employed in construction work.* Cancer of Stomach, Colon, and Ilectuin.--ln our' From the life table we determined for each of the earlier study of asbestos workers,' there were more-n: 370 men the probability of his dying within a pe deaths than expected from cancer of the stomacn. ; riod of 52 months, considering his age on Jan l, colon, and rectum (9.4 expected, 29 observed). As " 1963, and assuming that the life table probability compared with a Lolal of I.*S expected deaths from * applied to him. Summing these probabilities for the these causes, there were cighL observed deaths in ,. 370 men yielded an estimate of the "expected" this study, due to cancer of the following sites: number of deaths under the null hypothesis that stomach, three; colon, four; and rectum, one. Al-;N. the age-specific death rates of these asbestos work though this bears out our earlier findings, the num-"v ers are the same as for United States white males her of deaths from these causes was so small tbaovii \ in1 general. The computation indicated that 47.5 *v we still refrain from drawing any conclusion at-? I desaatths would have heen expected. YV5, *V\^-t-.TToZ. / this time. ' ~Next, we wished" t6"estimate the expected num- Asbestosis.--Ashestosis accounted for 15 of the.-*.' her of deaths from each of several causes. For this, 94,.dcaths. While' it is not surprising that deaths-'*!, we made use of the percentage distribution of from this`disease occur among men exposed to-'... deaths by cause of death among United States ashestoa dust, intention must he called (> the n*c'"- 448061 06292 ASBESTOS EXPOSURE--SELIKOFF ET AL 103 that these subjects were primarily insulation work Table 4.--Estimated Number of Lung Cancer Ueaths Cxpccted to-Occur Durinsr a Period or 52 Months per 10,000 Men Living at the Start uf Period; by Age and by Smoking Habits* *T ers. While all of them ';\S were occupationally ex posed to asbestos dust, A|?. Yr Smoked U*n 1. 1963) Rtftutarl/ Ciu-ir Only Eiclio.il. Smokrt( 1-9 4 04/ Current Cif-.r.lt. Smokmt 10-19 04/ 4 04/ 40+* 4 04/ their degree of exposure 35-39 0 ...r 5 was light as compared with the degree of ex 40-44 .5-49 so-s 2 2 7 12 75 . 10 22 28 ... 44 15 39 69 15 45 00 I- posure of asbestos miners, '*JC processors, and weavers 55-59 60-6* 65-69 6 16 14 in earlier times. 70-74 12 IS 53 91 117 ! 35 31 71 30 no 256 32 97 ... 157 305 350* 52 100 103 205 ?8A 4S0* Bronchogenic Carci 75-79 80-84 23 25 S3 100 . . . 185 341 325 3? M8 noma.--Bronchogenic car cinoma accounteii~for~24 8aed upon data Irom a prospcetwt study wth adjustment tor US mortality epeM#nc* t Ellipses indicate rates omitted lor categories th no sudiects m this study. So* TaJ,'l* 2 deaths while" only about (Includes cigarette smokers who also smoked p.oe or cigar. Men with a history of only ciearetta smoking have higher lung cancer rates than snown here. 2.3 were expected ori'the $Aates obtained by smoothing the data. hnsis of generarUhitecLStates mortality, data for divided into many five-year age groups, some of the whi.te_male3. However, as previously mentioned, subgroups contained only 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'srnall 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 m Table 4' carry very little weight in the carcinoma deaths, the smoking habits of the men final calculation. All-of the rates were then ad being taken into consideration. This was done as justed as follows; S 'lows; Lung cancer death rates in the United Slates Data are available on lung cancer deaths in re have risen steadily year by year and were higher lation to the smoking habits of 440,000 men en in 1964 than during the period 1960 to 1964 as a rolled by American Cancer Society volunteers in whole. Furthermore, in the study described above, _ a prospective epidemiological* studybetween Oc we avoided enrolling sertBtfsly ill people and, as of tober 1959 and March 1960 and traced through the cut-off date for prfiParing tfit* computer tape, Sept 30,1964. Causes of death were ascertained from we had not yet received death certificates for all death certificates,-but whenever cancer was men- .. of the men now known to have died during the tinned on a death certificate inquiry was made_of- specified period of time. For these reasons, lung . the phvsician_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 j; 'V mation,. the physician's statement was accepted. males in the United States in 1964. To compensate 4, Fortlie purpose at hand, wc only made use of data for this, we raised the rate of each individual smok covering the 52-month period beginning on June 1, ing category so that the total lung cancer death I960, and ending on Sept 30, 1964. The number of rate (disregarding smoking habits) in each five- lung cancer deaths occurring during the 52-month year age group would be the same as that of all period was divided by the number of men alive at United States white males (baser! upon the 1964 the beginning of the 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 rooking categories: (1) never smoked regularly are shown in Table 4. (It should be noted that nonsmokers and occasional smokers being com Table 4 shows only such rates as were required for bined); (2) history of regular pipe or cigar smok- further calculations.) ,ng. past or present, hut never smoked cigarettes The rates shown in Table 4 were then applied to fegularly; (3) excigarette smokers (including those the number of asbestos workers shown in each of *ho had smoked or currently smoked pipes or the corresponding internal cells of Table 2. This tigars); and (4) current regular cigarette smokers yielded an estimate of the number of lung cancer V including those who also had smoked or currently deaths expected to occur during a 52-month period A "ed pipes or cigars). The last of these catcfc-.es was further divided by current number of among the 370 asbestos workers classified by their smoking habits. By "expected" number, we here garettes smoked per day; (4a) one to nine ciga- mean an estimate of the number of lung cancer rettes a day; (4b) 10 to 19 cigarettes a day; (4c) deaths which would have occurred under the null T to D9 cigarettes a day; and (4d) 40 or more hypothesis that asbestos workers do not differ from fl;arcttes a day. Since the men were divided into other men in respect to their lung cancer death ^en groups by smoking habits and further sub rates, ix>lh age and smoking fiafiiK fifing taken 06293 448062 no ASBESTOS EXPOSURE-SELIKOFF ET AL Table 5.--Observed and Expected Bronchogenic Carcinoma men who never smoked cigarettes regularly. How. Deaths by Smoking Habits* for 370 Asbestos Workers ever, considering the small number of such subjects- Smoking Habit* Never smoked regularly History of flifl*. c>tar smoking only Hitlory of rogvtar tigartlia tmoklngf Observed Ocaths 0 0 24 Exprch'd Oeath* o.os 0.13 2.98 in this study, we only.conclude that exposure, to asbestos dust does not gneatly increase the. risk .of- 1 anchogenic carcinoma, among.men . who..never smoked cigarettes regularly. Tolel 24 306 *8asad upon data in Table 2 and Table X. tlneludee cigarette smokers who also smoked flips or cigar. Twenty-four of the rnen with a history of regular cigarette smoking died of bronchogenic carcinoma - whereas only 2.98 were expected to die of it, a ratio of 8.05 to 1. From this it appears that exposure to Table 6.--Expected and Observed Deaths Among 632 Asbes asbestos dust greatly increases the risk of lung tos Workers Exposed to Asbesto Dust 20 years or Longer cancer among cigarette smokers. Totil deaths: alt causes Expected Observed Total cancer: all sites Cxoected Observed Cancer of lun*. trachea, pleura Expected Observed Cancer of stomach, colon, rectum Expected Observed Cancer ail other sites combined Expected Observed Asbestosis Expected Observed All other causes xDcted Observed 1843*1962 203.3 255 Tots! 1963-1957 1943-1967' 47.5 94 251 349 36.3 93 8.6 49 45.1 144 6.6 43 2.3 27 3.9 72 9.4 29 1.8 11.2 3 37 20.3 21 4.5 14 2S 35 O0 12 IS 0 27 167 38.9 205.9 148 30 178 Now we may ask how greatly is the risk of bron chogenic carcinoma increased by the combined of. fects of cigarette smoking and exposure to asbestos. dust. To answer this question, we applied rates shown in Table 4 for nonasbestos workers who- never smoked regularly to the number of subjects with a history of regular cigarette smoking as shown . / in Table 2. This indicated that only 0.26 of the subjects with a history' of regular cigarette sn.rTr-ir. would have been expected to die of bronchogenic carcinoma if they had never smoked regularly end - had never been occupationally exposed to asbestos - dust. Since 24 of them actually died of this cause, the ratio of observed to expected deaths is 92 to 1 (ie, 24 divided by 0.26=92). This appears to in dicate that- cigarette smoking plus occupational into consideration. The results are summarized in Table 5 which shows the expected and observed number of lung cancer deaths in each of three smoking categories. Taking smoking habits as~well as age into con sideration (Table 5) a total of 3.2 bronchogenic carcinoma deaths were expected whereas taking only age into consideration.. 2.3 deaths were ex pected from this cause (Table 3). Thus, perhaps one of the excess bronchogenic carcinoma deaths might be attributed to the fact that there appear to have been proportionally somewhat more ciga exposure to asbestos dust increases the risk of bronchogenic carcinoma by a factor in the order of magnitude of 92 to 1. It should be noted that this estimate does not take current amount of cigarette smoking into consideration. .. Comparison With Earlier Findings.--As explained, we started with^.-fflfohort ofjX'52 asbestos insulation workers, the entire membership of the union locals on Jan 1, 1943. We have now traced each man through April 30, 1967. Table 6 shows the observed and expected number of deaths for each of two periods (the first, 1943 to J962, being previously reported1) and for the entire period. In respect to rette smokers among the 370 subjects than among respiratory cancer (lung, trachea, and pleura) and men of the same ages in the general population. in respect to cancer of the stomach, colon, and The following statements are based upon the rectum, the findings in the two periods arc in close data shown in Table 5. Twenty-four deaths from agreement. bronchogenic carcinoma occurred among the 370 subjects compared with only 3.16 expected, a ratio Comment of about 7.6 to l. This is slightly higher than found - The increased risk of neoplasia (mainly broncho in our earlier study which indicated a ratio of 6.3 genic carcinoma and mesothelioma) among insula to 1 (not taking smoking habits into considera tion workers reported here should he evaluated in tion). It should be noted in this connection that the the knowledge that tiiese men .have comparatively 370 subjects in this study had been exposed to light exposure as asbestos trades go. Primarily em asbestos dust somewhat longer than the subjects of ployed in construction work, many of the materials - our previous study (the present 370 subjects are tficy. use contain, little or no asbestos and others survivors as of Jan 1, 1963, of subjects in the have_only.5%.to.15%. Conditions of work vary; . . previous study). these, men often work outdoors unlike asbestos - Of the subjects who never smoked regularly and operators in factory work. Comparatively few dust- those who smoked only pipes or cigars, none died exposure surveys have been made in tins trade but of bronchogenic carcinoma whereas 0.18 of these their results have generally been within the 5 mil- men were expected to die of lung cancer. This sug- . lion particles per cubic foot permissible limits cur gests that exposure to asbestos dust does _npt.ii rently accepted by the American Conference of crease the risk of bronchogenic carcinoma among\ Governmental Industrial Hygienists.'''1" Nor have irw 06294 448063 V* ASBESTOS EXPOSURE--SEUKCFF ET AL 1U >jee; r > 1 5k of .n\-iever additional potentially carcinogenic substances been identified among the other materials used.1 Heavier or even lighter exposure may result in diirerent degrees of risk of neoplasia. Heavy factory oMiosure in the past has in some instancea_resuited in cohsulern.Hlelu'ng cancer risk*?7" In others, para - 40 years ago. Youngster.- who start smoking nowhave a much greater chance of having both ex posures simultaneously. Significance of Findings for Asbestos Workers.-- The import of the data reported here sems clear. There.is an extraordinary risk of developing and ;ular "loma ratio re to '. lung : (lexically, little lung'cancer wajf seen_because_as- dying from lung cancer for asbestos workers "who fjestosts j.yas_so common and so severe..as JO.cause .smoke cigarettes regularly. In the group" studied. deatlT o? the exposed workers'before_they.could live . the combination of asbestos exposure and cigarette long enough to develdp'luhg*cancer. .Once exposur\/ smoking increased Hie risk approximately 90 times Teas'reduced by irripfoved"industr(a) .hygiene prac*-fs compared with men who neither work with asbestos dees, early death'from asbestosis sharply-dimin- nor smoke! . iron--ri ef- "A jtos 4:& rates -*! who iy , ject3 -A- iown \!a the =;. king <* ;enic -V; and istos u #uise, -l to 1 j,. in- \ onal k cy*~N ,1 -trh0is 'ette isHed' and lung'cancer became .common.'1 In any case, heavy exposure is not likely to be the most important problem in the future, unless there be sheer carelessness or unconcern. Rather, light exposure, similar to that in insulation work, will be much more common, both in direct asbestos working trades and as the result of indirect occupa tional exposure, as in the construction-and ship building industries. .There is another type of "light exposure" which may affect many more people than those industrial ly exposed. In the past several years, it has been demonstrated that asbestos bodies can be found in the lungs of 25% to 50% of adults examined at autopsy in large cities, such as Belfast, Northern Ireland, Capetown, Republic of South Africa, Miami, Fla, Pittsburgh, and Montreal. This is presumably due to "asbestos air pollution" by ^/fibers derived from industrial "spillover" (as dust from construction sites or factory wastes) or from end-product use. Such community asbestos air Of 283 asbestos workers who had a history' of cigarette smoking, 78 died within a period of 52 months whereas only 32.4'would have beer, ex pected to die within that length of time if their age specific death rates had been the same as for tiie general white male population of the United States. Of the 78 deaths, 24 (31%) were due to broncho genic carcinoma. It is estimated that if these men had smoked cigarettes but had hot been exposed to asbestos dust, only 2.9S would have died of bron chogenic carcinoma within the same length of time. If they had neither smoked nor been exposed to asbestos dust, only 0.26 would have been expected to die of the disease within a period of 52 months. Of 87 asbestos workers who never smoked ciga rettes regularly, none died of lung cancer within the '52-month period- (although three died of asbestosis and one died of peritoneal mesothelioma). This finding, being based upon the experience of only 87 men, does not prove that exposure to asbestos dust has no influence jia-the risk of lung cancer ned, r pollution may be important since there is already tion evidence that in certain circumstances, as living cals within half mile of an asbestos plant or in the nan household of an asbestos worker, intimate environ ved mental contamination can he associated with some .wo risk of mesothelioma.'1 What is not now known is siy ; whether the minimal amounts inhaled by the gen to ' eral public carry a similar risk." nd Nor do we know whether inhalation of the very nd t small amounts of asbestos present in the air of some ise . communities is associated with a special lung cancer risk in .cigarette smokers (or, conversely, among nonsmokWSC However, it.suggests.that ex posure to ashtsifos "dust does not lend--to an ex tremely high risk of lung cancer among, nonsmokers. The conclusions are evident: 1. Occupational exposure to asbestos dust should be reduced l.o as low a level as possible; but there may be an irreducible minimumlevbrjf asbestos,.a very.useful material, is to be usecLuit at], Such reduction in exposure will benefit asbestos workers of tiro future. However, we are also concerned with workers who have already been exposed at sign.nennt levels for many years. Asbestos fibers will re whether cigarette smoking makes the inhalation of main in their tissues (or the. remainder of their live*. very small amounts of asbestos particularly hazard- _ 2. All people incur a great- increase in ri*k of iung o- pus). It will he important to ascertain whether such * cancer if they smoke cigarettes; for asbestos work ain coearcinogenic or potentiating or precipitating rela ers the increase in risk is tremendous. Asbestos tionships exist because, with the rapid growth of workers who do not. now smoke cigarettes should 'y 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 !s S year now), it may be diincult' 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 be easy to unravel the interrelation asbestos workers as well. 'n\ t ships which might exist between community as bestos air pollution and cigarette smoking. Both asbestos exposure and cigarette smoking have a long-lapsed period between onset of exposure and was supported l*y the Health Kc^eurch Coun cil of Ih# CUy of New York. References 1. SclikofT, [X; Cliurt!. r.; ami K.H.: A>Vi*4Jto Kx- occurrence of neoplasia, yet for current smokers these two exposures may not have begun simulta pmure ntt Nrtipl*****, >h\MA (April t!> IfH4 2. Sf*Iko(f. lJ.; Chtirf;. ,1.; ami Hnmmontl, K.C: Uelalion II*- lwr*n to ANl>r-.r< ml Mc^olhWtom** New Kng J Med neously; there was much less asbestos used 20 to Sra&SQ'fitift (Man'll !H> !*** i i 448064 112 ASBESTOS EXPO PJHE-SEUKOFF ET *L 3. f Inminimd, K.C "Siiiokinr in Ki-lnlitiii to thi? I)i*.ith Kales o( 1,000,000 Mon unrt Wmin," in Kpitlemtnlnjuni Study of Cancer and Olhtr Chrome Disrate*. Bethe-Xx. Md: National Cancer Institute. lOfiO, monograph 19, pp 127-20-1. 4. Smoking and ttealth. K*-|xwl nf the Advisory Committee to the Si-eon General of,the Public Health Service, publication 1103. US Dept ol Health. Education, anil Welfare, 1964. 5. Hammond. K.C.. and Carlinkel. I..: Chnnges in Cignrettn Smoking 1959-1003. Amee J Public Health 53:30-45 (.Inn) 1908. G, Vital Statistic* of th(_ United Slalt*. 1960, part A. US Dept of Health, Education, anil Welfare. 19*13, vol 2. 7, Death Rate* From Malignant Neoplasms. I960. Public Health Service, publication 1213, US Dept of Health, Education, anil Welfare. 1963. 8. Mortality by Occupation and Cause of Death. Public Health Service. US Dept of Health. Education, and Welfare, Vila! Sin- ti-.tiui Division. Vital Statistics--Special Etcports. 53:323 (S-r,u lOh.3. 9. Fleischer, W.K., et nit A Health Survey of I'ipe-<Vnrnr.r Operations in Constructing Naval Vc.-s.vels. J Industr ffvg Tone 28:9-16 (Jim) 1946. 10. Keane. W.T, and Z.ivun, Nf It.: Occupational Iln/auK oI Pipe Insulators. Arch Environ Health 1.7:171-178 (Aug) It'll; 11. Doll. It.: Mortaiilv From l.ung Cmccr m Asbestos Workers. Brit J Industr Med 12:61-66 (April) 1953. 12. Jacob. O., anil An-pach, M.: Pulmonary Neoplasia An.i,. ,,Dresden Asbestos Workers, Ann NY Acad Sc (32d>36-t'i.th Ujt-c 31) 1965. 13. Newhouse, MX.. end 37iom:/son. ft.: * Mesothelioma of I'loprn and Peritoneum Following Kxiwxure to Asbestos m (he London Area, Brit J Industr Med 22:2Gl-2u9 (Oct) 1965. 14. SelikoiT, IX. et al: AsbesUwis and Neoplasia, Amer J Med 42:487-496 (April) 1967. Many, possibly most, of the words in the dictionary stand there as representatives of a whole family of forms. Not even the timidcst 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 he authorized by implication the moment the infinitive is known to exist. The plurals of nouns are similarly taken for 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 ail its grammatically possible forms. (For details, consult your grammar.) But is a gerund a grammatical form? Or is it a su/lix-derived noun? T am not really looking for an answer. I ask those questions to suggest that the dividing line between grammatical form and derived neologism is both hard to de fine and artificial. If I distinguish--among men--the "hunting" from the "hunted," I have done no more than form (grammatically) two nouns from two adjectives which are forms (grammatically) implied in the existence of "to hunt." But if "hunting" is implied* why not "hunter"? Why not "huntee" gpcl "huntabie" and "huntabilize'*? ---- ----------- - The question of when a new word is anew-word- and when it is merely an "im plied" farm of !T6)AVrilional term ls-indced-msn rnmpltix-tfaan is-grossly ap parent Take "dehnirability" TTS'an example. Can' f'Cfnim the word is implied in the existence of "hair," or must I assume the rcsjjonsibility for having spawned a monster? ----- - Or take "uneqtdvocably," which indeed-wa3 the.starting point of all this rea soning and wonderingr for it xr.is sisjtted-ns a bold neologism-in JAjVLA-ijv-thc sentence, "Research at the Public Health Service Hospital at Lexington, Ky, has-- unequivocably proven that methadone has all of the euphoria properties of morphine. ..." Now, clearly, Uie adverb "unequivocably" is grammatically implied in the ad jective "unequivocahte," and this in tufa is implied--grammatically of semi-graxu- matically or otherwise--in "oquivocable." If wo grant further that formations in "-able" of "-ible" are likewise legitimate without special dispensation, wv shall conclude that "unequivocably" is in no sense a hold departure since "lo equivo cate" is a firmly established, standard English word. lint there is a hitch and a flaw in the argument. "To equivocate" means "to use ambiguous language" and (by extension) "to render ambiguous." ifence, "oquivocable" can only suggest the trait of "being apt or able to ho made ambig uous," and that, I fear, was not intended. Which means, by (nongmmmaUcal) implication, that the discrepancy between the obviously intended meaning of "un- equivocably" and its structurally supported significance was the cause of the un pleasant jolt experienced hy the spotting reader*/ /JS.~It is of course possible, and even likely, that "unequivocably" was just a typo for "equivocally." Acj-jcahdku Gouts, FjlD 0629& ' ISM* A---1 ^ Vni ?q-1 ,*ln 2 448065