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Smoking and Occupational Health

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4. Presence of COPD may increase the amount of workplace particulate retained in ... COPD: Multiple occupational substances ... COPD: Coal Dust and Smoking ... – PowerPoint PPT presentation

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Title: Smoking and Occupational Health


1
Smoking and Occupational Health
  • Association of Occupational and Environmental
    Clinics (AOEC)
  • National Institute for Occupational Safety and
    Health (NIOSH)
  • Curriculum Models in Occupational Health
  • Developed by
  • William S. Beckett M.D., M.P.H., Dina Markowitz
    Ph.D.
  • Occupational Medicine and Pulmonary and Critical
    Care Divisions
  • University of Rochester School of Medicine and
    Dentistry

2
Introduction
  • Many cases of occupational lung disease formerly
    attributed to smoking alone
  • Occupational hazards and smoking remain common
    both pose risks to workers.
  • Interactions may be additive, or greater than
    additive.
  • Most smokers do not develop significant lung
    disease, but interaction with occupational
    exposures increases risk

3
Interactions Between Occupational Exposures and
Smoking
  • Additive the effect of combination of agents is
    the same as the sum of individual effects
  • Greater than additive (multiplicative
    synergistic) effect is more than the sum of
    individual effects
  • Antagonistic one factor reduces the excess
    disease caused by another.

4
Overview Smoking/Workplace Interactions
  • A. Lung Diseases
  • 1. Malignant
  • 2. Non-malignant
  • B. Cardiovascular Disease
  • C. Urologic (Bladder, Kidney) Diseases
  • D. Injuries and mortality

5
Outcome Measures for Interactions
  • Disease Incidence
  • Disease severity
  • -- Symptoms
  • -- Pulmonary Function
  • (FEV1,Diffusing capacity)
  • -- X-ray changes
  • Premature Mortality

6
Smoking Related Respiratory Disease
  • Caused by cigarette smoking
  • Chronic bronchitis
  • COPD (Emphysema)
  • Bronchiolitis
  • Lung Cancer
  • Affected by cigarette smoking
  • Asthma
  • Fibrosis

7
The Spectrum of Occupational Lung Disease
8
Past Smoking Prevalence in US Males by Birth
CohortUS Dept of Health and Human Services . The
Health Consequences of Smoking. A Report of the
Surgeon General. 1985
9
Current Workplace Smoking Prevalence
  • Smoking prevalence lowest among White Collar
    Workers, highest among Blue Collar and Service
    Workers
  • Gap between White and Blue Collar Workers appears
    to be widening
  • Blue Collar and Service Workers less likely to
    quit
  • Blue Collar Workers are heavier smokers
  • Giovino GA, NIOSH Scientific Workshop on Work,
    Smoking and Health, 2000.

10
Smoking / Workplace Interactions Mechanisms
  • 1. Toxins in smoke may also be present in
    workplace (e.g. carbon monoxide)
  • 2. Chemicals may be transformed into more harmful
    agents by smoking
  • 3. Smoking may increase delivery or retention of
    agents
  • 4. Presence of COPD may increase the amount of
    workplace particulate retained in the lung
  • Adapted from Dement, NIOSH Scientific Workshop,
    Work, Smoking and Health, 2000

11
Smoking/Workplace Interactions Lung Diseases
  • A. Malignant (Cancer)
  • B. Non-malignant
  • Asthma
  • COPD
  • Pulmonary Fibrosis

12
Smoking Workplace InteractionsAsbestos and Lung
Cancer
  • A multiplicative interaction has been found for
    asbestos and cigarette smoking.
  • This may occur for other known occupational
    causes of lung cancer arsenic, bis- and
    chloro-chloromethyl ether, cadmium, chromiumVI,
    silica (crystalline), mustard gas, nickel, radon,
    ionizing radiation, soots, tars, mineral oils

13
Inhaled Asbestos Fibers And Cigarette Smoke
Penetrate Airway Epithelial Cells to Cause
Mutations in DNAArrows asbestos fiber M
macrophage Ep Airway epithelial cell
  • (Illustration from a mouse inhalation model using
    asbestos fibers)
  • Brody et al. Am Rev Respir Dis 1981 123 670-9

14
Smoking Workplace InteractionsAsbestos and Lung
Cancer
  • Heavy (e.g. gt11/2 packs per day) lifetime
    cigarette smoking increases risk for lung cancer
    10-fold or more heavy career-long asbestos
    exposure increases lung cancer risk 5-fold
    combination is multiplicative (10 x 5 50 fold).
  • Selikoff et al. J. Am. Med Assoc. 1964 18822

15
Smoking Workplace InteractionsLung Cancer
  • Intervention Smoking cessation reduces risk for
    lung cancer risk drops progressively over 10
    years of disease-free follow-up, but excess risk
    may be lifelong for heavy smokers
  • Smoking cessation has been found to reduce risk
    for lung cancer in heavily-exposed asbestos
    workers

16
Non-Malignant Lung Diseases
  • Asthma gt 200 occupational substances cause
    asthma smoking can make disease worse
  • Chronic Bronchitis smoking and dusts are
    additive
  • COPD Multiple occupational substances interact
    with smoke
  • Pulmonary Fibrosis Smoking a risk factor for
    some forms and interacts with occupational
    exposures in some forms.

17
Asthma Interactions
  • gt 200 workplace substances known to cause asthma
  • Smoking increases asthma severity, but
    association with causation inconsistent
  • Smoking increases risk for occupational asthma
    caused by some substances
  • Smoking accelerates lung function loss in
    asthmatics
  • Venables et al Br Med J 1989 299939.

18
Asthma
  • Smoking may increase risk of workplace
    sensitization to
  • Acid Anhydrides Colophony
  • Flour Antigens Lab Animals
  • Platinum Salts
  • Taylor, Int Arch Allergy Appl Immunol 198782435
  • Venables, Br Med J 1989299939.

19
Case Report Combined Effects of Asbestos
(Fibrosis) and Cigarettes (Emphysema)
  • History 74 year old retired laborer who worked
    in shipyard, welding, and demolition 67
    pack-year smoking
  • X-Ray emphysema, pleural plaque, linear
    opacities both bases
  • Pulmonary Function FEV1 47 predicted, FVC 81
    predicted, FEV1/FVC 44, DLCO 11 predicted,
  • Autopsy Asbestosis and emphysema
  • Case 32-1986 the Mass. Gen. Hospital New Engl J
    Med 1986315437

20
Combined Effects of Asbestos and Cigarettes on
Lung Function
  • 383 employed shipyard and manufacturing workers,
    mean age 41-45
  • ?Effects of asbestos exposure and smoking tested
    in multivariate statistical models
  • Additive, independent effects of asbestos and
    cigarette smoking were seen on decreased forced
    vital capacity and on single breath diffusing
    capacity
  • Samet et al., Am Rev Respir Dis 197912075.

21
Asbestos and Cigarette Smoking Autopsy Lung of
a Patient Who Died with Asbestosis
22
COPD (Chronic Obstructive Pulmonary Disease)
Occupational Causes
  • Examples of workplace exposures that interact
    with smoking to cause chronic obstructive
    pulmonary disease
  • Coal Dust
  • Silica
  • Cotton Dust
  • Cadmium
  • Diisocyanates (MDI, HDI, TDI)

23
Interaction of Asbestos and Cigarette Smoking to
Increase X-ray Markings (Normal Chest X-Ray ILO
Category 0/0)
24
Interaction of Asbestos and Cigarette Smoking to
Increase X-ray Markings (Asbestosis, ILO Category
2/2)
  • Smoking increases the profusion of small
    opacities on
  • x-rays in asbestosis Weiss W. Am Rev Respir Dis
    1984 130293-301

25
Asbestos and Cigarette Smoking Interaction on
Chest X-ray ILO Category
  • Asbestos causes pulmonary fibrosis, while smoking
    usually causes emphysema (destruction of alveolar
    surface area).
  • In those with asbestosis who have also been heavy
    smokers, there is (on average) an increase in the
    profusion of small linear opacities on chest
    x-ray.
  • A smoker may have one half category higher
    profusion than a non-smoker with equivalent
    asbestos exposure
  • Weiss, Am Rev Respir Dis 1984 130293-301.
  • Barnhart, Am Rev Respir Dis 1990 1411102

26
COPD Coal Dust and SmokingRetired coal miner
and former smoker demonstrates melanoptysis
expectoration of coal dust from lungs

27
COPD Smoking and Coal Dust Chest X-ray of
retired coal miner demonstrates Coalworkers
Pneumoconiosis with Progressive Massive Fibrosis

28
Smoking and Coal Dust Retired Coal Miners
Pulmonary Function Tests
  • FVC 2.18 liters 71 of Predicted
  • FEV1 0.95 40
  • FEV1/FVC ratio 43
  • TLC 4.89 93
  • VC 2.22 73
  • FRC 3.37 104
  • RV 2.67 121
  • DLCO 8.6 45
  • (Severe obstructive abnormality, gas transfer
    defect)

29
COPD Coal Dust
  • Lung with Coalworkers Pneumoconiosis
  • Nodular fibrosis with focal emphysema

30
COPD Smoking and Coal Dust
  • In an epidemiologic study of autopsy lungs from
    coal miners for whom smoking histories were
    available, pathologic degree of emphysema was
    associated both with coal dust and smoke
    exposure, independent of the effects of coal dust
    causing nodular fibrosis.
  • Conclusion Smoking/Coal Dust Additive
    Interaction Causes Emphysema
  • Vallyathan et al. Ann Occ Hyg 199741(Suppl
    1)352

31
Cardiovascular Disease
  • Smoking a major risk factor for myocardial
    infarction, death, peripheral vascular disease
  • Multiple workplace factors (carbon monoxide,
    carbon disulphide, and possibly workplace stress)
    may contribute to risk
  • Combinations of smoking and workplace factors may
    increase risk

32
Cardiovascular Disease Carbon Monoxide
  • Carbon monoxide in cigarette smoke is
  • suspected of contributing to excess
    cardiovascular mortality in smokers.
  • A mortality study of New York City tunnel workers
    exposed to 50 (mean) up to 400 parts per million
    carbon monoxide (before ventilation improvements
    in 1970) had 35 increased cardiovascular
    mortality compared to control bridge workers.
  • Stern et al. Am J Epidemiology 19881276.

33
Urologic Disease Bladder Cancer
  • After lung, bladder cancer is the most common
    fatal, occupational malignancy
  • Proportion of bladder cancer attributable to
    occupational exposures has been estimated at 21
    to 25 for males and 11 for females in U.S.
  • Silverman DT. Am J Epidemiol 1990132453

34
Bladder Cancer
  • Causative factors (recognized or strongly
    suspected) smoking, benzidine, benzidine dyes,
    3,3-dichlorobenzidine, nitrobiphenyl,
    4,4-methylene-bis(2-chloroaniline) (MOCA),
    4,4-methylene dianiline (MDA).
  • Goldstein et al., Bladder Carcinogens, in
    Environmental and Occupational Medicine, W. Rom,
    ed., Lippincott, 1998.

35
Integration of smoking cessation with
occupational health and safety programs
  • Workplaces may be either enabling or discouraging
    to healthy behaviors such as smoking cessation
  • Integrating tobacco control program into a
    comprehensive occupational health and safety
    program may be more effective than having
    separate programs.

36
Effects of workplace smoking bans
  • Studies of smoking among employees after
    implementation of workplace smoking bans show
    reduced total cigarette consumption in employees
  • Benefits included reduced active smoking and
    reduced passive smoke exposure to non-smokers

37
Interventions to prevent occupational inhalation
exposures
  • Substitution of less hazardous materials
  • Process containment (prevention of release of
    hazards into breathing air)
  • Local exhaust ventilation
  • General area ventilation
  • Respiratory protective devices

38
Disability and Workers Compensation
  • State Workers Compensation rules may require
    physician to apportion the per cent of
    pulmonary disability that is work-related and
    non-work related.
  • Relative effects of smoking and occupational
    exposures in population studies may be helpful in
    apportionment decisions.
  • Attfield. Longitudinal decline in FEV1 in
    United States coalminers. Thorax 1985132-137.

39
Resources for Reading
  • Work, Smoking and Health. Proceedings of a NIOSH
    Scientific Workshop
  • Strasser PB. Smoking Cessation Programs in the
    Workplace Review and recommendations for
    Occupational Health Nurses. American Association
    of Occupational Health Nurses Journal,
    199139432.
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