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To identify opportunities for targeted prevention, we explored differences in occupational mortality from diseases and injuries related to alcohol consumption, sexual habits and drug abuse.
Using data on all deaths among men and women aged 16-74 years in England and Wales during 1991-2000, we derived age- and social class-standardised proportional mortality ratios (PMRs) by occupation for cause of death categories defined a priori as potentially related to alcohol consumption, sexual habits or drug abuse.
The highest mortality from alcohol-related diseases and injuries was observed in publicans and bar staff (both sexes), and in male caterers, cooks and kitchen porters, and seafarers. Male seafarers had significantly elevated PMRs for cirrhosis (179), “other alcohol-related diseases” (275), cancers of the liver (155), oral cavity (275) and pharynx (267), and injury by fall on the stairs (187). PMRs for HIV/AIDS were particularly high in tailors and dressmakers (918, 95%CI 369-1890, in men; 804, 95%CI 219-2060, in women) and male hairdressers (918, 95%CI 717-1160). Most jobs with high mortality from HIV/AIDS also had more deaths than expected from viral hepatitis. Of seven jobs with significantly high PMRs for both drug dependence and accidental poisoning by drugs, four were in the construction industry (male painters and decorators, bricklayers and masons, plasterers, and roofers and glaziers).
Our findings highlight major differences between occupations in mortality from diseases and injuries caused by alcohol, sexual habits and drug abuse. Priorities for preventive action include alcohol-related disorders in male seafarers and drug abuse in construction workers.
Historically, national and regional analyses of mortality by occupation have been carried out mainly to identify and characterise hazards in the workplace, and to assess the impact of controls on such hazards. However, the health of occupational groups may also differ importantly for other reasons. We here present findings from a 10-year analysis of occupational mortality in England and Wales, focusing on diseases and injuries related to alcohol consumption, sexual habits and abuse of drugs. In some cases the findings point to opportunities for targeted preventive measures.
The Office for National Statistics supplied us with data on all deaths at ages 16-74 years in England and Wales during 1991-2000. For each death, we were given the sex, age, year of death and last full-time occupation of the decedent, together with the underlying cause of death. Occupations were coded to the Standard Occupational Classification 1990 (SOC 90), categories of which were aggregated to 181 non-overlapping job groups. Causes of death were coded to the ninth revision of the International Classification of Diseases (ICD 9). Social class was defined from occupation according to a standard algorithm.
Analysis was based on deaths for which there was an adequately described occupation (1,202,888 men and 408,152 women). Associations between job group and cause of death were summarised by sex-specific proportional mortality ratios (PMRs) standardised for age (in five-year bands) and social class. PMRs were expressed as percentages, with associated 95% confidence intervals (CIs) based on the Poisson distribution.
For the purposes of this report, we focused primarily on a pre-defined set of cause of death categories potentially related to one or more of alcohol consumption, sexual habits and drug abuse. In addition, we examined mortality from two smoking-related diseases (cancer of the bronchus and chronic obstructive pulmonary disease (COPD)), where this might shed light on patterns of mortality from the diseases of main interest. Full details of the causes of death analysed are given in Appendix A. For a part of the study period (1993-2000), we were also given the decedent’s place of birth. This information was also used to explore possible explanations for observed patterns of mortality.
Five job groups had significantly elevated PMRs (lower 95% confidence limit >100) for at least four of the eight categories of alcohol-related disease that we examined – male seafarers, publicans and bar staff, caterers, and cooks and kitchen porters; and female publicans and bar staff. Table 1 summarises patterns of mortality in these job groups for diseases caused by alcohol and also for cancer of the bronchus and chronic obstructive pulmonary disease (COPD). PMRs were consistently elevated for all the alcohol-related diseases other than cancer of the oesophagus, although their relative magnitudes varied between job groups. For example, caterers and cooks and kitchen porters had markedly higher PMRs than seafarers and publicans and bar staff for cancer of the liver, but lower PMRs for “other alcohol-related diseases”, cirrhosis, and cancers of the oral cavity and larynx. PMRs for cancer of the bronchus and COPD were also lower in caterers and cooks and kitchen porters.
Table 2 shows mortality in the same job groups from four categories of injury and from suicide. Deaths from falls and from injury by fire, were generally more frequent than expected, the largest excesses being for deaths caused by falls on stairs. On the other hand, PMRs for motor vehicle traffic accidents and suicide were consistently (and often significantly) less than 100.
Table 3 lists job groups with significantly elevated PMRs for HIV/AIDS, and shows also their PMRs for viral hepatitis and the ratios of PMRs for the two diseases. Several of the PMRs for HIV/AIDS were remarkably high, notably in tailors and dressmakers (918, 95%CI 369-1890, in men; 804, 95%CI 219-2060, in women), and in male hairdressers (918, 95%CI 717-1160). Furthermore, most of the job groups with high mortality from HIV/AIDS also had more deaths than expected from viral hepatitis. For most job groups, the ratio of the PMR for HIV/AIDS to that for viral hepatitis was between 0.8 and 1.3, and for several others, the 95%CI for the ratio embraced this range. Exceptions, however, were male hairdressers (ratio = 5.8, 95%CI 1.6-49) and “other service personnel” (ratio = 3.5, 95%CI 1.9-6.6).
Analysis of deaths by place of birth indicated that among cooks and kitchen porters the proportion of men who had been born in South Asia (6.9%) was higher than in all occupations combined (1.8%). Moreover the proportion of deaths from viral hepatitis was much higher in men born in South Asia (0.4%) than in those born in the UK (0.03%).
Table 4 summarises mortality from drug dependence and accidental poisoning by drugs in job groups that had significantly elevated PMRs for both of these causes of death. All seven of the job groups that satisfied this criterion were in men, including four in the construction industry together with literary and artistic occupations, retailers and dealers, and “other labourers”. The ratio of PMRs for the two causes of death was fairly consistent across these occupations.
The findings presented highlight major differences between occupational groups in mortality from diseases and injuries related to alcohol, sexual activity and abuse of drugs. In some cases, the high risks identified, although not directly attributable to hazards in the workplace, may point to useful opportunities for prevention.
Our method of analysis was subject to various well-documented limitations. Errors are known to occur in the recording of occupations and causes of death on death certificates,[4,5] and even where accurate, occupational data related only to the decedent’s last full-time job. Also, the PMR of a job group for a specific cause could be spuriously inflated if mortality in the job group from all causes combined was unusually low. However, it is extremely unlikely that biases of this sort could explain the substantially elevated PMRs that we have demonstrated in this report.
The job groups with highest mortality from alcohol-related diseases were mostly in the catering industry, a finding that has been noted before, and which has persisted through to 2005. It is unsurprising, given the ready access to alcoholic drinks in these occupations. Indeed, publicans and bar staff may be directly encouraged to consume alcohol during the course of their work by offers of free drinks from customers. To this extent, their risk of alcohol-related disease could be regarded as a true occupational hazard. In addition, however, there may be a tendency for people who drink more heavily, selectively to seek jobs in establishments where alcohol is served. Moreover, employment in such environments may encourage a culture of drinking outside working hours.
Cultural influences of this sort could also be one reason why male seafarers have high mortality from alcohol-related diseases. Many sailors work in small, closed communities, in which drinking habits can easily be transmitted to others. In addition, the stresses associated with absence from home for prolonged periods may be a further contributing factor. High rates of alcohol-related disease in seamen have been reported also in other countries,[6,9,10] and should be a priority for preventive action. There is scope for employers to control access to alcohol while ships are at sea, as some already do. Furthermore, statutory periodic health checks of a kind that British merchant seamen are obliged to undergo, offer opportunities for health promotion at the individual level.
Interestingly, relative mortality from different alcohol-related diseases differed markedly between job groups. Caterers and cooks and kitchen porters had higher PMRs for liver cancer than publicans and bar staff and seafarers, but lower PMRs for oral cancer, laryngeal cancer, cirrhosis and “other alcohol-related diseases”. Their lower mortality from oral and laryngeal cancer may in part reflect a lower prevalence of smoking, in support of which, they also had their lower PMRs for cancer of the bronchus and COPD (Table 1). In addition, however, it is notable that caterers and cooks and kitchen porters also had unusually high mortality from viral hepatitis (Table 3). Chronic hepatitis B and C infections are a major cause of liver cancer in their own right,[12,13] and the risk of liver cancer from these infections is enhanced by alcohol consumption.[13,14]
Occupations with high mortality from diseases related to alcohol also had high PMRs from injury by falls (especially falls on stairs) and by fire (Table 2). This seems likely to reflect an increased risk of such injuries in people who are intoxicated by alcohol, and is consistent with previous findings on mortality by occupation from falls on stairs. In contrast, however, their mortality from motor vehicle traffic accidents and suicide was lower than expected. In the case of motor vehicle accidents, this may be because people in the occupations concerned drive less than those in other jobs.
Mortality from HIV/AIDS varied widely between jobs, with PMRs in male hairdressers and tailors and dressmakers more than nine times the average for all occupations. A major factor in this is likely to be differences between job groups in the prevalence of homosexuality, rates of HIV infection being higher in male homosexuals. A second influence may be the frequency of intravenous drug abuse, shared use of needles being another important route by which the virus is transmitted. Hepatitis B and C can also be transmitted in this way, and this may explain why many of the job groups with high PMRs for HIV/AIDS also had high mortality from viral hepatitis. In addition, rates of hepatitis are likely to be elevated in occupations that include higher proportions of immigrants from countries where the infection is prevalent in early life. For example, the cooks and kitchen porters in our study included a relatively high proportion of men who had been born in South Asia (6.9% compared with 1.8% for all occupations combined), while the overall proportion of deaths that was from viral hepatitis was much higher in South Asian men (0.4%) than among men born in the UK (0.03%). This additional reason for hepatitis in some occupations may partly explain why the ratio of the PMR for HIV/AIDS to that for viral hepatitis varied between job groups.
Consistent with an increased risk of HIV/AIDS and viral hepatitis from shared use of needles, male literary and artistic occupations were among the job groups with high mortality from drug dependence and accidental poisoning by drugs. Interestingly, however, most of the other job groups with elevated PMRs for drug-related deaths were in the construction industry (painters and decorators, bricklayers and masons, plasterers, and roofers and glaziers). This may be because men who abuse drugs tend to seek work in casual jobs, and it does not necessarily imply a culture of drug abuse in the construction industry. Nevertheless, it could contribute to the high rate of occupational injuries in construction trades. There would be merit, therefore in further research to establish the scale of the problem, and the potential for targeted interventions to reduce it.
In summary, this analysis has highlighted major variation between occupations in mortality from a number of diseases and injuries that are unlikely to be caused directly by work. In the case of alcohol-related disorders in male seafarers, there may be immediate opportunities for preventive action. In addition, there would be value in exploring further the extent of drug abuse in construction workers, and the scope for preventive measures in the workplace.
We thank the Office of National Statistics for providing us with data. The Health and Safety Executive provided financial support for analytical work carried out by the Health and Safety Laboratory. Clare Harris was funded by the Colt Foundation. Vanessa Cox helped in preparation of data files at the MRC Epidemiology Resource Centre.
|Cause of Death||Component ICD9 Categories|
|Cancer of oral cavity||141||Malignant neoplasm of tongue|
|143||Malignant neoplasm of gum|
|144||Malignant neoplasm of floor of mouth|
|145||Malignant neoplasm of other and|
unspecified parts of mouth
|Cancer of pharynx (specified)||146||Malignant neoplasm of oropharynx|
|147||Malignant neoplasm of nasopharynx|
|148||Malignant neoplasm of hypopharynx|
|Cancer of oesophagus||150||Malignant neoplasm of oesophagus|
|Cancer of liver||155||Malignant neoplasm of liver and|
intrahepatic bile ducts
|Cancer of larynx||161||Malignant neoplasm of larynx|
|Other alcohol-related diseases||303||Alcohol dependence syndrome|
|571.0||Alcoholic fatty liver|
|571.1||Acute alcoholic hepatitis|
|571.2||Alcoholic cirrhosis of liver|
|571.3||Alcoholic liver damage (unspecified)|
|E860.0||Accidental poisoning by alcoholic|
|E860.1||Accidental poisoning by other and|
unspecified ethyl alcohol and its
|Cirrhosis (without mention of|
|571.5||Cirrhosis of liver without mention of|
|Cancer of the bronchus||162||Malignant neoplasm of trachea,|
bronchus and lung
|Chronic obstructive pulmonary|
|496||Chronic airway obstruction not|
|Motor vehicle traffic accidents||E810-E819||Motor vehicle traffic accidents|
|Fall on stairs||E880||Fall on or from stairs or steps|
|Fall unspecified||E888||Other and unspecified fall|
|Injury by fire||E890-E899||Accidents caused by fire and flames|
|Suicide||E950-E959||Suicide and self-inflicted injury|
|HIV/AIDS||042||Human immunodeficiency virus (HIV)|
|279.1||Deficiency of cell-mediated immunity|
|Viral hepatitis||070||Viral hepatitis|
|Drug dependence||304||Drug dependence|
|Accidental poisoning by drugs||E850-E858||Accidental poisoning by drugs,|
medicinal substances and biologicals