rHE HEALTH CONSEQUENCES OF SMOKING CANCER AND CHRONIC LUNG DISEASE IN THE WORKPLACE ~ areport of the Surgeon General U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Servi Office on Smoking and Health Rockville, Maryland 20857 THE HEALTH CONSEQUENCES OF SMOKING CANCER AND CHRONIC LUNG DISEASE IN THE WORKPLACE a report of the Surgeon General 1985 © #) U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES i Public Health Service = { Office on Smoking and Health Rockville, Maryland 20857 For sale by the Superintendent of Documents. U.S. Government Printing Office Washington, DC 20402 THE SECRETARY OF HEALTH AND “UMAN SERVICES WASHINGTON DC 2029: MAY $355 The Honorable Thamas P. O'Neill, Jr. Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: It is a pleasure to transmit to the Congress the final edition of the Surgeon General's Report on the Health Consequences of Smoking, as mandated by Section 8 (a) of the Public Health Cigarette Smoking Act of 1949. This is the Public Health Service's 17th Report on this topic and, like earlier Reports, identifies cigarette smoking as one of this Nation's most serious public health problems. This Report, which provides a detailed review of the relationship between smoking and hazardous substances in the workplace, is particularly disturbing because of the added health burden that many workers Carry if they smoke cigarettes. As this Report makes clear, for some workers this added burden is substantial. No better example exists to illustrate this interaction than the case of asbestos workers. Current scientific evidence indicates that heavily exposed asbestos insulation workers who did not smoke may experience a 5-fold increase in lung cancer campared to nonsmoking, nonexposed workers. However, if this same worker also smoked, his lung cancer risk is increased more than 50-fold. Also disturbing is the continued high rate of current cigarette use among blue collar workers compared to their white collar counterparts. These workers are more apt to be exposed to dusts and other harmful substances in their workplace environments. Programs to reduce workplace hazardous exposures are helping to offset these risks. For the majority of workers who smoke, cigarette smoking poses a greater risk to health than does occupational exposure. Thus, elimination of cigarette smoking among such workers can have a profound effect on improving their health. This Department has a strong commitment to prevention and health pramotion. It is essential that workplace health promotion programs have a strong focus on reducing cigarette amking among employees to the extent possible. These efforts can not only have an effect on the health of the individual, but may also have a substantial impact by reducing absenteeism on the job, thereby improving productivity and reducing health care costs. Cigarette smoking is associated with an estimated $23 billion in health care costs annually and over $30 billion in lost productivity and wages. Toa certain degree we all share these costs whether we smoke or not. Programs that reduce smoking, therefore, can have a benefit to all our society. Sincerely, 2.07 tr Otis R. Bowen, M.D. Secretary Enclosure 2 Ee THE SECRETARY OF HE OL TH AND HUMAN SERVICES HASHINGTON DC 2620 Hi yaw MAY 41986 The Honorable George Bush President of the Senate Washington, D.C. 20510 Dear Mr. President: It is a pleasure to transmit to the Congress the final edition of the Surgeon General's Report on the Health Consequences of Smoking, as mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969. This is the Public Health Service's 17th Report on this topic and, like earlier Reports, identifies cigarette smoking as one of this Nation's most serious public health problems. This Report, which provides a detailed review of the relationship between smoking and hazardous substances in the workplace, is particularly disturbing because of the added health burden that many workers carry if they smoke cigarettes. As this Report makes clear, for some workers this added burden is substantial. No better example exists to illustrate this interaction than the case of asbestos workers. Current scientific evidence indicates that heavily exposed asbestos insulation workers who did not smoke may experience a 5-fold increase in lung cancer compared to nonsmoking, nonexposed workers. However, if this same worker also smoked, his lung cancer risk is increased more than 50-fold. Also disturbing is the continued high rate of current cigarette use among blue collar workers compared to their white collar counterparts. These workers are more apt to be exposed to dusts and other harmful substances in their workplace environments. Programs to reduce workplace hazardous exposures are helping to offset these risks. For the majority of workers who smoke, cigarette smoking poses a greater risk to health than does occupational exposure. Thus, elimination of cigarette smoking among such workers can have a profound effect on improving their health. This Department has a strong commitment to prevention and health promotion. It is essential that workplace health promotion programs have a strong focus on reducing cigarette smoking among employees to the extent possible. These efforts can not only have an effect on the health of the individual, but may also have a substantial impact by reducing absenteeism on the job, thereby improving productivity and reducing health care costs. Cigarette smoking is associated with an estimated $23 billion in health care costs annually and over $30 billion in lost productivity and wages. To a certain degree we all share these costs whether we smoke or not. Programs that reduce smoking, therefore, can have a benefit to all our society. Sincerely, OWT tor Otis R. Bowen, M.D. Secretary Enclosure FOREWORD Over the past generation, the actions of labor unions, manage- ment, insurers, and Government have made substantial progress in reducing exposure to hazardous substances in the workplace. This Report acknowledges this progress, and demonstrates clearly that these efforts to protect the American worker must continue. There can be no relaxation in our efforts to continue the safeguards already in place or to seek new safeguards as new hazards are identified. This Report also establishes that for these efforts to protect the worker to fully succeed, these same forces of labor, management, insurers, and Government must become equally engaged in attempts to reduce the prevalence of cigarette smoking, particularly among those working populations most at risk. For the majority of workers who smoke, cigarette smoking poses a greater risk to health than does occupational exposure. This 1985 Report of the Surgeon General examines in greater depth than ever before the relationships between cigarette smoking and occupational exposures; it is a document of singular importance. As with previous Reports, a large number of experts and scientists recruited from both within and outside the Federal service have participated in developing and reviewing the content of this Report. I express here my respect and gratitude for their efforts. Donald fan Macdonald, M.D. Acting Assistant Secretary for Health vii PREFACE The 1985 Report on the Health Consequences of Smoking presents a comprehensive review of the interaction of cigarette smoking with occupational exposures in the production of cancer and chronic lung disease. Cigarette smoking and its relationship to cancer and chronic obstructive lung disease (COLD) were extensively reviewed in the 1982 and 1984 Surgeon General’s Reports, respectively. In the 1982 Report, cigarette smoking was judged to be the leading cause of cancer mortality in the United States; a causal association was found between smoking and cancer of the lung, larynx, oral cavity, and esophagus, and smoking was identified as a contributory factor in the development of cancer of the bladder, kidney, and pancreas. In 1984, cigarette smoking was identified as the major cause of COLD, which includes chronic bronchitis and emphysema, among both men and women in the United States. The contribution of other factors in COLD morbidity and mortality was found to be far less important than that of cigarette smoking. This Report examines the evidence available on the role played by cigarette smoking and occupational exposure in the development of cancer and chronic lung disease. Cancer and chronic lung disease are major causes of death in the United States, accounting for well over 25 percent of all deaths annually. Cancer mortality rates have shown a steady increase, unlike rates for the major cardiovascular diseases, which have declined over the last two decades. Chronic lung disease, now the fifth leading cause of mortality, has been increasing more rapidly than other major causes of death. It is estimated that more than 10 million Americans report suffering from these diseases. Findings of the 1985 Report The major overall conclusions of this Report are these: For the majority of American workers who smoke, cigarette smoking represents a greater cause of death and disability than their workplace environment. In those worksites where well-established disease outcomes occur, smoking control and reduction in exposure to hazardous agents are effective, compatible, and occasionally synergistic ix approaches to the reduction of disease risk for the individual worker. Smoking and occupational exposures can interact synergistically to create more disease than the sum of the separate exposures. This kind of interaction is exemplified by the relationship between asbestos exposure and smoking. A study of heavily exposed asbestos insulation workers, more than 20 years after onset of exposure, demonstrated a fivefold increased risk for lung cancer among nonsmoking asbestos workers compared with nonsmokers without asbestos exposure. We know that in non-asbestos-exposed popula- tions, smoking increases the lung cancer risk approximately tenfold. The risk is increased more than fiftyfold if the asbestos workers also smoke. This risk in cigarette-smoking asbestos workers is greater than the sum of the risk of the independent expos'1res, and is approximated by multiplying the risks of the two separate expo- sures. In other words, for those workers who both smoke and are exposed to asbestos, the risk of developing and dying from lung cancer is 5,000 percent greater than the risk for individuals who neither smoke nor are exposed. Thus, the interaction of cigarette smoking and asbestos exposure is multiplicative. For asbestos workers, the risk of developing and dying of lung cancer increases with an increasing number of cigarettes smoked per day and with an increasing asbestos exposure. For example, the risk is 87 times greater for those workers who smoke more than one pack per day. The risk declines among workers who are able to stop smoking, compared with the risk for those who continue to smoke. An interaction for the production of lung cancer also exists between cigarette smoking and the radon daughters exposure of miners, although the exact nature of this interaction is not clear. Both cigarette smoking and exposure to certain occupational hazards increase the risk for chronic lung disease. These risks can occur independently or may combine to produce a greater degree of lung injury than would have occurred from either exposure separate- ly. While many exposures are capable of producing chronic lung injury, either independently or in combination, smoking appears to be the more important exposure for the majority of U.S. workers. Differences in Smoking Behavior Between White-Collar Workers and Blue-Collar Workers This Report also presents detailed findings with regard to differ- ences in smoking prevalence between blue-collar workers and white- collar workers. Blue-collar workers are more likely to be exposed to workplace agents, which, in combination with their higher smoking rates, may place these workers at considerable excess risk for cancer and chronic lung disease. Although these differences exist among both men and women, they are more pronounced among men. The differences in the prevalence of smoking between blue-collar workers and white-collar workers may underestimate the differences found among specific populations of occupationally exposed workers. As noted in this Report, individual studies among certain workers report current smoking rates well in excess of 50 percent. In addition, in one of the largest studies of asbestos workers, more than 80 percent of the men in the cohort had been regular cigarette smokers during their lifetime and only 11 percent were classified as never having smoked regularly. These differences in smoking behavior make the control for smoking behavior an important part of the design of studies of the relationship of occupational exposures and cancer or chronic lung disease. On the average, blue-collar men initiate smoking approximately 14 months earlier than white-collar men. We know from existing studies that an earlier age of initiation is strongly correlated with increased mortality for lung cancer and chronic lung disease as well as for most other smoking-related diseases. Even with this earlier age of initiation, a substantial fraction of blue-collar workers begin smoking coincident with their entry into the workforce, and blue- collar workers are less likely than white-collar workers to be able to successfully quit smoking. Smoking Control in the Workplace The potential role of the workplace in promoting initiation and fostering the continuation of smoking behavior represents a kind of interaction between smoking and the workplace that may affect large numbers of U.S. workers. It seems clear that the responsibility for health in the workplace includes at minimum a work environ- ment that does not promote smoking or interfere with cessation. The worksite offers an opportunity for implementation of smoking cessation programs. A number of studies cited in this Report found worksite-based programs to be more successful than clinic-based programs, probably owing to their more intensive nature and because many employer-sponsored programs offer economic and other incentives, thus enhancing their success. The goal in public health, both in the worksite and outside it, is the reduction and elimination of disease and the promotion of healthy behavior. The content of this Report makes it clear that the elimination of chronic lung disease and cancer from the workplace cannot succeed without a companion effort to alter the smoking behavior of workers. It is precisely those occupations in which the greatest occupational hazards have existed that smoking cessation also yields the greatest return for individual worker’s health. It xi should be obvious that smoking cessation efforts are an adjunct to, and not a substitute for, occupational environmental controls. Correspondingly, a concern about workers’ health that limits itself to the control of environmental exposure levels disregards the major health benefits of smoking cessation. C. Everett Koop, M.D. Surgeon General xii ACKNOWLEDGMENTS This Report was prepared by the U.S. Department of Health and Human Services under the general editorship of the Office on Smoking and Health, Donald R. Shopland, Acting Director. Manag- ing Editor was William R. Lynn, Acting Technical Information Officer, Office on Smoking and Health. Senior scientific editor was David M. Burns, M.D., Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of California at San Diego, San Diego, Califor- nia. Consulting scientific editors were Ellen R. Gritz, Ph.D., Asso- ciate Director for Research, Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of California at Los Angeles, Los Angeles, California; John H. Holbrook, M.D., Associate Professor of Internal Medicine, University of Utah Medical Center, Salt Lake City, Utah; and Jonathan M. Samet, M.D., Associate Professor of Medicine, Department of Medicine, The University of New Mexico School of Medicine, Albuquerque, New Mexico. The following individuals prepared draft chapters or portions of the Report. Victor E. Archer, M.D., Clinical Professor, Rocky Mountain Center for Occupational and Environmental Health, The University of Utah Medical Center, Salt Lake City, Utah Michael E. Baser, M.S., Chief, Occupational Health, Bureau of Environmental Epidemiology and Occupational Health, New York State Health Department, Albany, New York David M. Burns, M.D., Associate Professor of Medicine, Divisicn of Pulmonary and Critical Care Medicine, University of California at San Diego, San Diego, California David B. Coultas, M.D., Instructor of Medicine, Department of Medicine and the New Mexico Tumor Registry, The University of New Mexico School of Medicine, Albuquerque, New Mexico John E. Craighead, M.D., Professor and Chairman, Department of Pathology, The University of Vermont College of Medicine, Burlington, Vermont Lori A. Crane, M.P.H., Staff Research Associate, Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of California at Los Angeles, Los Angeles, California xiii Philip E. Enterline, Ph.D., Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsyl- vania Russell E. Glasgow, Ph.D., Research Scientist, Oregon Research Institute, Eugene, Oregon David F. Goldsmith, Ph.D., Visiting Assistant Professor, Department of Internal Medicine, School of Medicine, University of California at Davis, Davis, California Robert C. Klesges, Ph.D., Associate Professor, Center for Applied Psychological Research, Department of Psychology, Memphis State University, Memphis, Tennessee Alfred C. Marcus, Ph.D., Program Director for Evaluation, Division of Cancer Control, Jonsson Comprehensive Cancer Center, Univer- sity of California at Los Angeles, Los Angeles, California Steven Markowitz, M.D., Environmental Sciences Laboratory, De- partment of Community Medicine, The Mount Sinai Medical Center, The Mount Sinai School of Medicine of the City University of New York, New York, New York James A. Merchant, M.D., Dr.P.H., Professor of Preventive and Internal Medicine, and Director, Institute of Agricultural Medi- cine and Occupational Health, The University of lowa College of Medicine, Iowa City, lowa Albert Miller, M.D., Clinical Professor of Medicine (Pulmonary), Clinical Professor of Community Medicine (Environmental), and Director, Pulmonary Function Laboratory, Division of Pulmonary Medicine, Department of Internal Medicine, The Mount Sinai Medical Center, The Mount Sinai School of Medicine of the City University of New York, New York, New York Donald P. Morgan, M.D., Ph.D., Professor, Department of Preventive Medicine and Environmental Health, The University of Iowa College of Medicine, lowa City, lowa W.K.C. Morgan, M.D., F.R.C.P.(Ed), F.R.C.P«C), F.A.C.P., Chest Diseases Unit, University Hospital, London, Ontario, Canada Brooke T. Mossman, Ph.D., Associate Professor of Pathology, and Chairman, Cell Biology Program, Department of Pathology, The University of Vermont College of Medicine, Burlington, Vermont Paul R. Pomrehn, Jr., M.D., Assistant Professor, Department of Preventive Medicine and Environmental Health, and Director, University Occupational Health Service, The University of Jowa College of Medicine, lowa City, lowa Howard E. Rockette, Ph.D., Professor of Biostatistics, Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania Jonathan M. Samet, M.D., M.S., Associate Professor of Medicine, Department of Medicine, The University of New Mexico School of Medicine, Albuquerque, New Mexico xiv Cecilia M. Smith, M.D., Assistant Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of California at San Diego, San Diego, California Melvyn S. Tockman, M.D., Ph.D., Associate Professor of Environ- mental Health Sciences, with joint appointments in Respiratory Medicine and Epidemiology, Center for Occupational and Environ- mental Health, The Johns Hopkins University, Baltimore, Mary- land Pamela H. Wolf, Dr.P.H., Biostatistician, Contraceptive Evaluation Branch, Center for Population Research, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland The editors acknowledge with gratitude the following distin- guished scientists, physicians, and others who lent their support in the development of this Report by coordinating manuscript prepara- tion, contributing critical reviews of the manuscript, or assisting in other ways. Charles A. Althafer, Assistant Director for Health Promotion and Risk Appraisal, Office of Program Planning and Evaluation, National Institute for Occupational Safety and Health, Centers for Disease Control, Atlanta, Georgia Harlan E. Amandus, Ph.D., Statistician, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, Centers for Disease Control, Morgantown, West Virginia Stephen M. Ayres, M.D., Dean, School of Medicine, Medical College of Virginia, Richmond, Virginia Mary A. Ballew, MS., Epidemiologist, Document Development Branch, Division of Standards Development and Technology Transfer, National Institute for Occupational Safety and Health, Centers for Disease Control, Cincinnati, Ohio Margaret R. Becklake, M.D., Professor, Departments of Medicine, Epidemiology, and Biostatistics, McGill University, Montreal, Quebec, Canada, on sabbatical, and Career Investigator, Medical Research Council of Canada, Montreal, Quebec, Canada, on leave; Professor (Honorary), Department of Community Health, Univer- sity of the Witwatersrand, and Principal Medical Officer, National Centre for Occupational Health, Department of Health and Welfare, Johannesburg, South Africa Kenneth R. Berger, M.D., Ph.D., Adjunct Assistant Professor, Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland Robert Bernstein, Senior Reviewer, Document Development Branch, Division of Standards Development and Technology Transfer, National Institute for Occupational Safety and Health, Centers for Disease Control, Cincinnati, Ohio XV Donald B. Bishop, Ph.D., Research Associate, Department of Psychol- ogy, Washington University in St. Louis, St. Louis, Missouri Brian A. Boehlecke, M.D., M.P.H., Associate Professor of Medicine, Division of Pulmonary Diseases, Critical Care and Occupational Medicine, Department of Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Lester Breslow, M.D., M.P.H., Co-Director, Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of California at Los Angeles, Los Angeles, California Benjamin Burrows, M.D., Professor of Internal Medicine, and Director, Division of Respiratory Sciences, The University of Arizona College of Medicine, Tucson, Arizona Robert M. Castellan, M.D., Chief, Clinical Section, Clinical Investiga- tions Branch, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, Centers for Disease Control, Morgantown, West Virginia John E. Davies, M.D., M.P.H., Professor and Chairman, Department of Epidemiology and Public Health, University of Miami School of Medicine, Miami, Florida Vincent T. DeVita, Jr., M.D., Director, National Cancer Institute, National Institutes of Health, Bethesda, Maryland John E. Diem, Ph.D., Professor of Statistics, Tulane University, New Orleans, Louisiana Manning Feinleib, M.D., Dr.P.H., Director, National Center for Health Statistics, Office of the Assistant Secretary for Health, Hyattsville, Maryland Edwin B. Fisher, Jr., Ph.D., Associate Professor of Psychology and Preventive Medicine, Department of Psychology, Washington University in St. Louis, St. Louis, Missouri Lawrence Garfinkel, M.A., Vice President for Epidemiology and Statistics, and Director of Cancer Prevention, American Cancer Society, Incorporated, New York, New York J.C. Gilson, M.D., Hembury Hill Farm, Honiton, Devon, England, United Kingdom William E. Halperin, M.D., M.P.H., Chief, Industrywide Studies Branch, Division of Surveillance Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Centers for Disease Control, Cincinnati, Ohio Peter V.V. Hamill, M.D., M.P.H., Adjunct Professor, Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland John L. Hankinson, Ph.D., Chief, Clinical Investigations Branch, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, Centers for Disease Control, Morgantown, West Virginia XV1 Naomi Harley, Ph.D., Professor, Institute of Environmental Medi- cine, New York University Medical Center, New York, New York Wayland J. Hayes, Jr., M.D., Ph.D., Professor Emeritus of Biochemis- try (Toxicology), School of Medicine, Vanderbilt University, Nash- ville, Tennessee lan T.T. Higgins, M.D., Professor Emeritus of Epidemiology and of Environmental and Industrial Health, School of Public Health, The University of Michigan, Ann Arbor, Michigan, and Acting Chief of Epidemiology, American Health Foundation, New York, New York Thomas K. Hodous, M.D., Medical Officer, Clinical Investigations Branch, Division of Respiratory Disease Studies, National Insti- tute for Occupational Safety and Health, Centers for Disease Control, and Adjunct Associate Professor, West Virginia Universi- ty School of Medicine, Morgantown, West Virginia Michael Jacobsen, Ph.D., Deputy Director, Institute for Occupational Medicine, Edinburgh, Scotland, United Kingdom Robert N. Jones, M.D., Professor of Medicine, Pulmonary Diseases Section, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana Marcus M. Key, M.D., Professor of Occupational Medicine, Program in Occupational Safety and Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas Kaye H. Kilburn, M.D., Ralph Edgington Professor of Medicine, Laboratory for Environmental Sciences, University of Southern California School of Medicine, Los Angeles, California Arthur M. Langer, Ph.D., Associate Professor of Mineralogy, The Mount Sinai School of Medicine of the City University of New York, New York, New York N. LeRoy Lapp, M.D., Professor of Medicine, Pulmonary Disease Section, West Virginia University Medical Center, Morgantown, West Virginia Richard A. Lemen, Director, Division of Standards Development and Technology Transfer, National Institute for Occupational Safety and Health, Centers for Disease Control, Cincinnati, Ohio Claude Lenfant, M.D., Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Trent R. Lewis, Ph.D., Chief, Experimental Toxicology Branch, Division of Biomedical and Behavioral Science, National Institute for Occupational Safety and Health, Centers for Disease Control, Cincinnati, Ohio Edward Lichtenstein, Ph.D., Professor of Psychology, University of Oregon, and Research Scientist, Oregon Research Institute, Eu- gene, Oregon xvii Ruth Lilis, M.D., Professor, Division of Environmental and Occupa- tional Medicine, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York, New York, New York Jay H. Lubin, Ph.D., Health Statistician, Biostatistics Branch, Division of Cancer Etiology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland James O. Mason, M.D., former Acting Assistant Secretary for Health, Washington, D.C., and Director, Centers for Disease Control, Atlanta, Georgia J. Corbett McDonald, M.D., F.R.C.P., Professor, School of Occupa- tional Health, McGill University, Montreal, Quebec, Canada J. Michael McGinnis, M.D., Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion), Office of the Assistant Secretary for Health, Washington, D.C. J. Donald Millar, M.D., Assistant Surgeon General and Director, National Institute for Occupational Safety and Health, Centers for Disease Control, Atlanta, Georgia Anthony B. Miller, M.B., F.R.C.P\C), Director, Epidemiology Unit, National Cancer Institute of Canada, and Professor of Preventive Medicine and Biostatistics, University of Toronto, Toronto, Ontar- io, Canada Kenneth M. Moser, M.D., Professor of Medicine, School of Medicine, University of California at San Diego, La Jolla, California, and Director, Division of Pulmonary and Critical Care Medicine, University of California Medical Center, San Diego, California Robert J. Mullan, M.D., Medical Officer, Surveillance Branch, Division of Surveillance Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Centers for Disease Control, Cincinnati, Ohio Muriel Newhouse, M.D., F.R.C.P., Department of Occupational Health and Applied Physiology, London School of Hygiene and Tropical Medicine, University of London, London, England, Unit- ed Kingdom William J. Nicholson, Ph.D., Associate Professor, Division of Envi- ronmental and Occupational Medicine, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York, New York, New York Judith K. Ockene, Ph.D., Associate Professor of Medicine, and Director, Division of Preventive and Behavioral Medicine, Depart- ment of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts C. Tracy Orleans, Ph.D., Clinical Assistant Professor, University of Pennsylvania Medical School, Philadelphia, Pennsylvania; Smok- ing and Health Consultants, Incorporated, Princeton, New Jersey XViii Carl E. Ortmeyer, Ph.D., Public Health Statistician (Retired), National Institute for Occupational Safety and Health, Centers for Disease Control, Morgantown, West Virginia John M. Peters, M.D., Professor, and Director, Division of Occupa- tional Health, Department of Preventive Medicine, University of Southern California School of Medicine, Los Angeles, California Richard Peto, M.A., M.Sc., LC.R.S., Requis Assessor of Medicine, Radcliffe Infirmary, University of Oxford, Oxford, England, Unit- ed Kingdom Philip C. Pratt, M.D., Professor of Pathology, Department of Pathology, Duke University Medical Center, Durham, North Carolina Edward P. Radford, M.D., Visiting Professor, University of Occupa- tional and Environmental Health, School of Medicine, Yahata Nishi-Ku, Kitakyushu, Japan Robert B. Reger, Ph.D., Chief, Epidemiological Investigations Branch, Division of Respiratory Disease Studies, National Insti- tute for Occupational Safety and Health, Centers for Disease Control, Morgantown, West Virginia Attilio D. Renzetti, Jr., M.D., Professor of Medicine, and Chief, Division of Respiratory, Critical Care, and Occupational Pulmo- nary Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah E. Neil Schachter, M.D., Professor of Medicine and Community Medicine, The Mount Sinai School of Medicine, and Director, Respiratory Therapy, The Mount Sinai Medical Center, The Mount Sinai School of Medicine of the City University of New York, New York, New York Richard S. Schilling, M.D., Department of Occupational Health and Applied Physiology, London School of Hygiene and Tropical Medicine, University of London, London, England, United King- dom Irving J. Selikoff, M.D., Professor Emeritus, The Mount Sinai School of Medicine of the City University of New York, New York, New York Kyle N. Steenland, Ph.D., Epidemiologist, Industrywide Studies Branch, Division of Surveillance Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Centers for Disease Control, Cincinnati, Ohio Jesse L. Steinfeld, M.D., President, Medical College of Georgia, Augusta, Georgia Arthur C. Upton, M.D., Professor, and Chairman, Institute of Environmental Medicine, New York University Medical Center, New York, New York John Christopher Wagoner, M.D., F.R.C.(Path), Medical Research Council Pneumoconiosis Unit, Llandough Hospital, Penarth, South Glamorgan, Wales, United Kingdom Kenneth E. Warner, Ph.D., Professor, and Chairman, Department of Health Planning and Administration, School of Public Health, The University of Michigan, Ann Arbor, Michigan David H. Wegman, M.D., M:S., Professor, Environmental and Occupational Health Sciences, School of Public Health, University of California at Los Angeles, Los Angeles, California Hans Weill, M.D., Schlieder Foundation Professor of Pulmonary Medicine, Tulane University School of Medicine, New Orleans, Louisiana William Weiss, M.D., Professor Emeritus of Medicine, Hahnemann University, Philadelphia, Pennsylvania “KR. Keith Wilson, M.D., Associate Professor of Medicine, Pulmonary Section, Baylor College of Medicine and The Methodist Hospital, Houston, Texas Ronald W. Wilson, M.A., Director, Division of Epidemiology and Health Promotion, National Center for Health Statistics, Office of the Assistant Secretary for Health, Hyattsville, Maryland James B. Wyngaarden, M.D., Director, National Institutes of Health, Bethesda, Maryland Frank E. Young, M.D., Commissioner, Food and Drug Administra- tion, Rockville, Maryland The editors also acknowledge the contributions of the following staff members and others who assisted in the preparation of this Report. Erica W. Adams, Chief Copy Editor and Assistant Production Manager, Health and Natural Resources Department, Informatics General Corporation, Rockville, Maryland Richard H. Amacher, Director, Health and Natural Resources Department, Informatics General Corporation, Rockville, Mary- land John L. Bagrosky, Associate Director for Program Operations, Office on Smoking and Health, Rockville, Maryland Charles A. Brown, Programmer, Automation and Technical Services Department, Informatics General Corporation, Rockville, Mary- land Clarice D. Brown, Statistician, Office on Smoking and Health, Rockville, Maryland Richard C. Brubaker, Information Specialist, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland Catherine E. Burckhardt, Secretary, Office on Smoking and Health, Rockville, Maryland XX Joanna B. Crichton, Copy Editor, Health and Natural Resources Department, Informatics General Corporation, Rockville, Mary- land Stephanie D. DeVoe, Programmer, Automation and Technical Services Department, Informatics General Corporation, Rockville, Maryland Terri L. Ecker, Clerk-Typist, Office on Smoking and Health, Rock- ville, Maryland Felisa F. Enriquez, Information Specialist, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland James N. Ferguson, Reproduction Technician, Office Services De- partment, Informatics General Corporation, Rockville, Maryland Danny A. Goodman, Information Specialist, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland Karen Harris, Clerk-Typist, Office on Smoking and Health, Rock- ville, Maryland Leslie J. Headlee, Information Specialist, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland Patricia E. Healy, Technical Information Specialist, Office on Smoking and Health, Rockville, Maryland Timothy K. Hensley, Technical Publications Writer, Office on Smoking and Health, Rockville, Maryland Shirley K. Hickman, Data Entry Operator, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland Ayse N. Hisim, Secretary, Health and Natural Resources Depart- ment, Informatics General Corporation, Rockville, Maryland Robert S. Hutchings, Associate Director for Information and Pro- gram Development, Office on Smoking and Health, Rockville, Maryland Leena Kang, Data Entry Operator, Health and Natural Resources Department, Informatics General Corporation, Rockville, Mary- land Carl M. Koch, Jr., Information Specialist, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland Julie Kurz, Graphic Artist, Information Center Management De- partment, Informatics General Corporation, Rockville, Maryland Maureen Mann, Editorial Assistant, Office on Smoking and Health, Rockville, Maryland James G. Oakley, Library Acquisitions Clerk, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland XX1 Ruth C. Palmer, Secretary, Office on Smoking and Health, Rockville, Maryland Russell D. Peek, Library Acquisitions Specialist, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland Roberta L. Phucas, Secretary, Office on Smoking and Health, Rockville, Maryland Margaret E. Pickerel, Public Information and Publications Special- ist, Office on Smoking and Health, Rockville, Maryland Raymond K. Poole, Production Coordinator, Health and Natural Resources Department, Informatics General Corporation, Rock- ville, Maryland Linda R. Sexton, Information Specialist, Health and Natural Re- sources Department, Informatics General Corporation, Rockville, Maryland Linda R. Spiegelman, Administrative Officer, Office on Smoking and Health, Rockville, Maryland Evelyn L. Swarr, Administrative Secretary, Automation and Techni- cal Services Department, Informatics General Corporation, Rock- ville, Maryland Debra C. Tate, Publications Systems Specialist, Publishing Systems Division, Informatics General Corporation, Riverdale, Maryland Jerry W. Vaughn, Development Technician, University of California at San Diego, San Diego, California Mary I. Walz, Computer Systems Analyst, Office on Smoking and Health, Rockville, Maryland Louise G. Wiseman, Technical Information Specialist, Office on Smoking and Health, Rockville, Maryland Pamela Zuniga, Secretary, University of California at San Diego, San Diego, California XXil TABLE OF CONTENTS FOre word 2.0... cc cccccc cece eee eee een vil PYOLACE o.oo ccc cece cece crete ene e beac nese een ee ee tees een eeeennns ix Acknowledgments..............0:0ceceee terete eee ne nes xiil 1. Introduction, Overview, and Summary and Conclusions ...... 0.00. ccc ccc eee ee eee eee te nee nnn ee een et enaees 1 2. Occupation and Smoking Behavior in the United States: Current Estimates and Recent Trends........ 19 3. Evaluation of Smoking-Related Cancers in the Workplace...........:c ccc cee ce cere ee ee ee ee ne nee ee eee e erent 97 4. Evaluation of Chronic Lung Disease in the Workplace..........0..ecccce scence tenner nen ee eie es 137 5. Chronic Bronchitis: Interaction of Smoking and Occupation .......... cece eet reenter tert ed 179 6. Asbestos-Exposed Workers ..........-::::s:esecee ene ene ene 195 7. Respiratory Disease in Coal Miners ..............-.+++: 285 8. Silica-Exposed Workers ...........:::eeeeeeeeeecene ee eee nes 319 9. Occupational Exposures to Petrochemicals, Aromatic Amines, and Pesticides ..............::cceeeee reese nee tnens 355 10. Cotton Dust Exposure and Cigarette Smoking....... 399 11. Ionizing Radiation and Lung Cancer ............-....:- 441 12. Smoking Intervention Programs in the Workplace........ ccc cece cece eee ee erence renner 473 Index coc ccccccccc cece e cece eee ene eee nee nner n eres 517 xxiii