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AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 31:534544 (1997)

Mortality Among a Cohort of Electric Utility Workers, 19601991


Michael A. Kelsh, MPH, MA, PhD,1* and Jack D. Sahl, MS, MPH, PhD2

Overall mortality trends among an electric utility workforce are examined. The study cohort (n 5 40,335) included all workers with at least 1 year of work experience from 19601991; 3,753 deaths were observed in this cohort. Standardized mortality ratios (SMRs) and internal cohort analyses were used to assess mortality trends for the entire cohort and for specic occupational groups. Most SMRs were #1.0 and were generally lower for noncancer (cardiovascular, COPD, and injuries) than for cancer mortality. Compared to offce staff, rate ratios (RR) were higher for respiratory cancers for eld staff [(RR 5 2.3, 95% CI, 1.05.0) linecrew (RR 5 2.2 95% CI, 1.53.1), and power plant occupations (RR 5 2.4, 95% CI, 1.63.6)]. Nonmanagement occupations had rate ratios for motor vehicle injuries and all types of injuries, within a range of 2.54.7, with all lower CIs .1.0. The healthy worker effect is an important factor in explaining the difference between SMR and internal cohort analyses results. The SMR results indicate that this workforce has lower rates for overall mortality, cardiovascular disease, cancer and nonintentional injury. A consistent nding in the internal cohort analyses that merits further research was higher mortality rates for respiratory cancer and injuries among nonoffce staff. Am. J. Ind. Med. 31:534544, 1997. r 1997 Wiley-Liss, Inc. KEY WORDS: mortality; electric utility workers; cohort; healthy worker effect

INTRODUCTION
Electric utility workers can be exposed to a wide range of chemical and physical agents. These exposures can include polychlorinated biphenyls (PCBs), chemical solvents (e.g. benzene, toluene), wood preservatives, pesticides and herbicides, lead and heavy metals (e.g., chromium and nickel), asbestos, noise, extremes of environmental heat and cold, and electromagnetic elds spanning the frequency range of ionizing radiation, visible light, radio and microwave, and power frequency elds. This workforce also shares a range of exposures from the community in which they live and exposures from their diet, exercise, and use of alcohol and cigarettes.

Inc., Ojai, CA. California Edison Company, Rosemead, CA. Contract Grant sponsor: Southern California Edison Company, Health Research and Evaluation Division. *Correspondence to: Dr. Michael A. Kelsh, Environmental Health Strategies, Inc., 149 Commonwealth Dr., Menlo Park, CA 94025. E-mail: Mkelsh@ envhealth.com
2Southern

1EcoAnalysis,

Accepted for publication 9 October 1996

Few studies have comprehensively analyzed mortality trends among an electric utility workforce or among utility workers in general. Such an analysis is useful in providing a better understanding of overall mortality trends that should help identify and prioritize efforts to improve occupational and public health for this workforce. As part of a comprehensive health research program, mortality data were collected and linked with personnel and occupational history information. Previous analyses of this workforce have focused on PCB exposures [Sahl et al., 1985], power frequency magnetic eld exposures [Sahl et al., 1994], power frequency magnetic eld exposure and cancer occurrence [Sahl et al., 1993], and injury occurrence [Kelsh and Sahl, 1996; Sahl et al., 1997]. The focus of this report is to provide an overview of the mortality experience among this workforce. We wanted rst to compare the mortality experience for the electric utility cohort to that of the general population. Second, we wanted to compare mortality risk between occupational groups within our utility worker cohort. The second type of comparisons provides an assessment for potential life-style and occupational impacts. Information on the relative mortal

r 1997 Wiley-Liss, Inc.

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ity experience within the cohort will serve as a better guide for identifying research priorities.

METHODS Cohort and General Population Mortality Data Definitions and Sources
The occupational cohort consisted of all noncontract personnel who worked for the Southern California Edison Company (Edison) for at least 1 year between 1960 and 1991. Occupational and demographic information was abstracted from company personnel records (computer les, microlmed records, benets and personnel folders, and employment cards). These data were linked with vital status and cause of death information. Annual age, sex, and race-specic mortality rates for the Edison workers and the general population residing in Los Angeles, Orange, Riverside, and San Bernardino counties were calculated using company personnel data, public mortality data, and U.S. census information.

Vital Status Assignment and Cause of Death Classification


We submitted record linkage data on personnel who were retired, terminated, or known deceased to several data clearance services to determine whether, and in what state, the employee had died. The data clearance services included the California Automated Mortality Linkage System (CAMLIS) [Arrellano, 1986], the National Death Index [NDI, 1985], and the Social Security Administration (SSA) beneciary records les [Aziz et al., 1982]. Death certicates were obtained based on information provided by CAMLIS, NDI and SSA records. Edison records also provided some death certicates that were not provided by the states or that were unavailable because the employee died out of the United States. We considered persons to be alive if they were active workers. Inactive workers were considered alive if there was no indication of death from Edison records or CAMLIS, NDI, and SSA data clearance procedures. The International Classication of Diseases (ICD) underlying and associated causes of death codes were abstracted from the death certicate. Only underlying causes of death were analyzed for comparative purposes with population mortality data. If the ICD underlying cause of death code was not available on the death certicate, a nosologist coded the underlying cause of death into the appropriate ICD revision (7th, 8th, or 9th). As part of an earlier analysis of magnetic eld exposures and cancer mortality, all death certicates were also coded into the ICD 9th revision codes. An occupational classication system was developed specically for this workforce for health analyses purposes. The

primary objectives of the occupational classication system were (1) to provide a consistent occupational grouping that accounts for historical changes in jobs, and (2) to collapse similar job titles into homogeneous groups with respect to job tasks and work environments. We further collapsed our 20 broad occupational categories into seven general groups: (1) management and professional; (2) administrative, technical, and clerical office workers; (3) service, material handlers and drivers; (4) meter readers and eld representatives; (5) linecrew (lineman, groundman, tree trimmers); (6) plant operators; and (7) plant craft workers (electricians, mechanics, machinists, welders, carpenters, and painters). These categories represent different work activities and work environments within this workforce. We dened an employees usual occupation as the occupation held for the longest time while employed at Edison. Usual occupation was treated as a xed variable in the analysis, unlike time dependent procedures used for assigning specic exposure scores. Job titles can represent a variety of exposures that we have not specied at this time. We also divided the total cohort into two groups based on length of service: #15 years and .15 years.

Supplemental Data
Information on personal life-style, such as smoking, alcohol consumption, and other factors, was not available for all individuals of the study cohort. However, several surveys on smoking patterns and alcohol consumption were conducted as part of ongoing occupational research programs at Edison. As part of a study to evaluate the impacts of implementing a smoke-free work environment policy, a smoking prevalence survey was conducted in 1993 through the use of telephone interviews at the worksite among a stratied random sample of Edison workers. These survey data were used to derive estimates of smoking preference by occupation. Smoking history was categorized as current smoker, former smoker, or never smoked. In a separate evaluation project of Nuclear Regulatory Commission (NRC) and Department of Transportation (DOT)-mandated substance abuse (drug and alcohol) testing programs, questionnaire data were collected on typical alcohol consumption. The survey sample included all DOT and NRC program participants (those workers involved in safety-sensitive occupations such as involving nuclear power or transportation activities) and a stratied random sample of other Edison employees (stratied by occupation). This survey was conducted in March 1995. Two types of alcohol consumption data are presented: (1) the frequency of consumption, and (2) the frequency of episodes of alcohol consumption involving ve or more drinks (often referred to as binge drinking).

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Statistical Methods
Standardized mortality ratio (SMR) analyses and internal cohort analyses were applied to the mortality data [Checkoway et al., 1989, Rothman, 1986]. For the internal cohort analyses, the administrative, technical, and clerical occupations were classied as the reference group, based on their large size and the observation that this group generally had the lowest SMRs when compared to the general population. We tabulated follow-up time from January 1, 1960 to the end of study date, December 31, 1991 using a modication of the Person-Years program [Coleman et al., 1989]. Using MantelHaenszel procedures for persontime data [Mantel and Haenszel, 1959; Greenland and Robins, 1985], we calculated summary rate ratios based on sex and for 5-year age intervals beginning with the 15- to 19-year age group and ending with 75- to 79-year-old subjects. Former employees over 80 years old were excluded from the analysis because the cause of death information for these age groups is less reliable than for younger age groups. (When 801-year-olds were included, this did not change the results reported here.) Cohort analyses (SMR and internal cohort) included both male and female workers. We compared the underlying cause of death for the six occupational groups to the internal reference group (administrative, technical, and clerical ofce staff). SMR analyses were performed for all Edison workers combined and for the seven occupational subgroups. The cohort was also categorized according to the length of employment with Edison. Two cutpoints were selected to assess employment duration effects: (1) ,10 years and $10 years, and (2) ,15 years and $15 years. We also calculated SMRs and rate ratios for the subgroup of workers who were active employees as of January 1, 1960 and the subgroup who began employment January 1, 1960 or later. Mortality rates for the southern California counties were used as the comparison group in the SMR analysis because they represented the general population from which the workforce arose. Ninety-ve percent condence intervals for the SMRs were obtained using an approximation procedure that assumes the denominator (the number of population cases) to be constant and that the observed number of cases (in the workforce) for a specic cause of death follows a Poisson distribution [Rothman and Broice, 1979; Checkoway et al., 1989]. Condence intervals for rate ratio estimates (internal cohort analyses) were calculated using GreenlandRobins methods [Greenland and Robins, 1985].

TABLE I. Demographic and Vital Status Summary of Electric Utility Cohort, 19601991
Total Cohort Vital Status Characteristics as of 12/31/91 Classication Active worker Out of service (alive) Retired (alive) Deceased (death certicate available) Deceased (no death certicate) Sex Male Female Missing Birth Decade 187089 189099 190009 191019 192029 193039 194049 195059 196069 197074 Unknown Race Black Asian/Pacic Islander American Indian Hispanic White Missing/Other Totals 17,635 13,454 5,345 3,753 19 30,450 9,788 97 2 389 1,428 2,235 4,270 5,761 11,770 9,862 4,334 194 90 43.8 33.4 13.3 9.3 ,.01 75.5 24.3 0.2 ,.0005 1.0 3.5 5.5 10.6 14.3 29.2 24.5 10.7 0.5 0.2 3,434 319 0 2 384 1,085 909 723 288 260 86 16 91.5 8.5 0.0 0.1 10.2 28.9 24.2 19.3 7.7 6.9 2.3 0.4 Number Percent Deceased Workers Number Percent

2,539 6.3 1,612 4.0 368 0.9 4,856 12.0 30,872 76.6 88 0.2 40,335 100.0

64 18 18 57 3,593 3 3,753

1.7 0.5 0.5 1.5 95.7 0.1 100.0

RESULTS
This cohort includes 40,335 workers for the 32-year period, 1960 to 1991. Fifty-six percent of this cohort were not working as of 1991. They had either left the company, retired or died. Forty-four percent of the cohort were active

workers (Table I). We observed 3,772 deaths among this workforce. We were unable to obtain death certicates for 19 people (0.1% of the deceased group). Males comprise about three quarters of the worker cohort. As of 1990, 65% of the cohort was 50 years old or younger; 10.6% were 5059 years old (Table I). The cohort is predominantly white (75.5%), with Hispanics as the next largest ethnic group (12.0%), followed by blacks (6.3%). The demographic prole of the deceased workers is substantially different, however; 95% were white and 91.4% were male. Because of the older age prole for whites, who accounted for most of the deaths in this cohort, and the small number of events among nonwhite race groups, especially when stratied by age and occupation, we did not adjust for race in the mortality analyses. These gures reect the rapidly chang-

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TABLE II. Occupational Prole of Electric Utility Workers, 19601991


Employment yearsa 53987.7 163096.7 30516.1 17570.6 103449.9 80229.6 46154.5 67306.5 562311.6 Follow-up yearsb 61639.3 211924.7 33869.5 19899.8 111189.2 94948.5 46941.5 63011.9 643424.2 Usual occupationc 3526 14672 2719 1747 5718 6222 2958 2773 40335

Occupational Group Management/Specialist/Supervisor Administrative/Technical/Clerical Service/Labor d Meter readers/Field service Linemen/Service appliance Trade/Craft Plant operatorse Other and missing Totals
aEmployment bFollow-up

% of total 9.6 29.0 5.4 3.1 18.4 14.3 8.2 12.0 100.0

% of total 9.6 32.9 5.3 3.1 17.3 14.8 7.3 9.8 100.0

% of total 8.7 36.4 6.7 4.3 14.2 15.4 7.3 6.9 100.0

years include work history from rst in-service date (including prior to 1960) to date of retirement or termination. years include study follow-up time by usual occupational category until end of study date (12/31/91) or date of death. cNumber of workers. Usual occupation dened as the occupation held for the longest time while employed at Edison. dService occupations include security staff, janitors, porters, food service, and landscaping/gardening occupations. ePlant operators include control room operators, plant equipment operators, and substation operators.

ing ethnic and demographic composition of this workforce. Since the 1960s, the age prole of the active workforce has shifted to older age groups, with a larger proportion of 40- to 49-year-old and 50- to 59-year-old workers (data not shown).

Occupational Profile
The occupational prole of the electric utility workforce by employment years, follow-up years, and number of employees is presented in Table II. The average length of service among all employees was 13.1 years, with a standard deviation of 9.6 years. In terms of the number of employees, clerical and technical personnel are the largest groups followed by linecrew personnel. The large proportion of employment and follow-up time for linecrew and eld and craft workers relative to the number of workers suggests that these occupations tend to stay in the workforce longer than clerical and technical personnel. We were unable to obtain occupational information for 6.9% of the cohort which represented 4.3% of the employment years and 9.8% of the follow-up years. These data are combined with the Other category in Table II.

ranged from 41% for office staff to 62% for service/labor occupations. The combined smoking prevalence (current plus former) may be a better reection of the smoking status of this cohort during periods of time relevant to disease outcomes analyzed in this study. The occupational categories of management, lineman, meter readers, plant operators, and trade/craft workers all had combined smoking prevalences of 5060%. The response rate for the smoking survey was 91%. There were similar self-reported alcohol consumption patterns for the seven electric utility occupational categories measured either by frequency of consumption (of any amount) or by episodes of binge drinking (data not shown). However, service and meter reader occupations had 11% or more workers reporting binge drinking three times or more per month, compared to an average of 6.4% for the other occupational groups. Lineman and management had the highest percentage of drinkers with 13% and 12% reporting ve or more drinking occasions per week. The response rate for this survey was 30%.

Underlying Cause of Death Distribution by Sex Among Electric Utility Workers


Cardiovascular diseases were the leading cause of death among male employees. For female employees, cancer (all types) was the leading cause of death (Table III). Among male workers, respiratory cancers were the most common type of cancer. Other more common cancers were digestive, prostate, and colon cancers. Lymphoma and leukemia accounted for 1.9% and 1.4%, respectively, of all deaths among male employees. There were no male breast cancers observed in the cohort. Chronic obstructive pulmonary disease (COPD), suicide, and inuenza each accounted for at least 2% of the deaths among males. All other specic

Smoking and Alcohol


Office staff had the lowest prevalence of smoking, measured either as a current (11%) or former smoker (30%). Management staff had similar prevalences for current smoking status, but a higher percentage of former smokers compared to office staff. Service/labor employees had the highest prevalence of cigarette smoking (22%), while trade and craft occupations had a smoking prevalence of 18%. For all occupational groups there were higher percentages of former smoking status, within a range of 3040%. The prevalence of current or former smoking status combined

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TABLE III. Underlying Cause of Death Distribution by Sex Among Electric Utility Workers
Males Underlying cause of death (ICD-9 Codes) All Causes (00009999) Cardiovascular (39004489) Ischemic Heart Disease (41004149) Other Cardiovascular (39004489) (excluding 41004149 & 43004389) Cerebrovascular (43004389) Cancers (14002089) Respiratory (16001659) Digestive (15001599) (excluding colon, 15301539) Prostate (18501859) Lymphoma (20002039) Leukemia (20402089) Breast (17401759) Brain (19101919) Colon (15301539)* Other (in 14002089) (not in any of the ranges listed above) Injuries (80009499) Motor Vehicle Injuries (81008259) Other Accidents (in 80009499) (not in 81008259) Chronic Obstructive Pulmonary Disease (COPD) (49004969) Suicide (95009599) Inuenza/Pneumonia (48004879) Diabetes (25002509) Homicide (96009599) Infectious Disease (00011399, not in 04200449) AIDS (04200449) Alzheimers Disease (3310) Parkinsons Disease (332) Other Unknown (0000) Females Totals

# males % of males % of total # females % of females % of total Total number Percent of total 3434 1466 969 321 176 958 360 117 95 65 48 0 25 98 150 268 128 140 129 96 74 29 28 29 17 11 9 318 2 100 42.7 28.2 9.3 5.1 27.9 10.5 3.4 2.8 1.9 1.4 0 0.7 2.9 4.4 7.8 3.7 4.1 3.8 2.8 2.2 0.8 0.8 0.8 0.5 0.3 0.3 9.3 0.1 91.5 39.1 25.8 8.6 4.7 25.5 9.6 3.1 2.5 1.7 1.3 0 0.7 2.6 4.0 7.1 3.4 3.7 3.4 2.6 2.0 0.8 0.8 0.8 0.5 0.3 0.2 8.5 0.1 319 95 51 25 19 130 19 17 0 5 3 34 5 15 32 24 15 9 9 9 4 3 6 1 1 2 3 31 1 100 29.8 16.0 7.8 6.0 40.8 6.0 5.3 0 1.6 0.9 10.7 1.6 4.7 10.0 7.5 4.7 2.8 2.8 2.8 1.3 0.9 1.9 0.3 0.3 0.6 0.9 9.7 0.3 8.5 2.5 1.4 0.7 0.5 3.5 0.5 0.5 0 0.1 0.1 0.9 0.1 0.4 0.9 0.6 0.4 0.2 0.2 0.2 0.1 0.1 0.2 ,0.1 ,0.1 0.1 0.1 0.8 ,0.1 3753 1561 1020 346 195 1088 379 134 95 70 51 34 30 113 182 292 143 149 138 105 78 32 34 30 18 13 12 349 3 100 41.6 27.2 9.2 5.2 29.0 10.1 3.6 2.5 1.9 1.4 0.9 0.8 3.0 4.8 7.8 3.8 4 3.7 2.8 2.1 0.9 0.9 0.8 0.5 0.3 0.3 9.3 0.1

causes of death accounted for less than 1% of the deaths among male workers (Table III). Breast cancer was the most common cancer among female workers followed by respiratory cancers. After cancer and heart disease, injuries were the third most common cause of death. Both males and females had similar proportions of deaths due to injuries (7.6% and 7.7%). The totals for the underlying cause of death include all individuals in the cohort.

SMR Analysis for Selected Causes of Death


Standardized mortality ratios were calculated excluding 801-year-olds and individuals who were missing demo-

graphic or in-service information. Twenty-nine records (deaths) were excluded because of missing demographic or in-service data, and 513 deaths were excluded because their age was $80 years. This reduced the total number of deaths from 3,753 to 3,211 for the SMR analysis. Among the entire Edison cohort, consistently low SMRs (,1.0) were observed for all selected causes of death except prostate cancer and leukemia (Table IV). The SMRs for prostate cancer and leukemia were 1.04 and 1.07, respectively. The SMRs were generally lower for noncancer outcomes (COPD, cardiovascular disease, injuries and suicide) than for cancer outcomes. The upper condence limits for all causes, all cancers combined, respiratory cancers, digestive system cancers, cardiovascular disease, COPD, injuries, and suicide were all

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TABLE IV. Standardized Mortality Ratios (SMRs) Among Electric Utility Workers for Selected Causes of Death
Males Underlying cause of death (ICD-9 codes) Cardiovascular (39004489) Cancers (14002089) Respiratory (16001659) Digestive (15001599) (excluding colon, 15301539) Prostate (18501859) Lymphoma (20002039) Leukemia (20402089) Breast (17401759) Brain (19101919) Colon (15301539) Injuries (80009499) Motor Vehicle Injuries (81008259) Chronic Obstructive Pulmonary Disease (COPD) (49004969) Suicide (95009599) OBS 1211 869 328 109 68 66 45 0 25 80 263 130 91 95 SMR 0.63 0.86 0.92 0.60 1.04 1.04 1.13 0.00 0.81 0.97 0.76 0.80 0.62 0.62 95% CI 0.590.66 0.800.92 0.821.03 0.490.72 0.811.32 0.811.32 0.821.51 0.521.19 0.771.21 0.670.85 0.670.95 0.500.76 0.500.75 OBS 66 113 18 13 0 5 3 26 4 13 22 14 8 9 Females SMR 0.51 0.84 0.73 0.82 0.72 0.58 0.80 1.13 1.28 0.75 0.94 0.70 0.53 95% CI 0.400.65 0.691.01 0.431.16 0.441.41 0.231.69 0.121.71 0.521.17 0.302.90 0.682.20 0.471.14 0.521.58 0.301.38 0.241.01 OBS 1277 982 346 122 68 71 48 26 29 93 285 144 99 104 Totals SMR 0.62 0.86 0.91 0.62 1.04 1.01 1.07 0.77 0.84 1.00 0.76 0.82 0.62 0.61 95% CI 0.590.65 0.800.91 0.821.01 0.510.74 0.811.32 0.791.27 0.791.41 0.501.13 0.561.21 0.811.23 0.670.85 0.690.96 0.510.76 0.500.74

,1.0. The SMRs for the higher categories of length of employment (.10 years and .15 years) were very similar to the ndings presented for the entire cohort (data not shown). Workers with $10 years of employment had slightly higher SMRs than those with ,10 years. The results were the same for the 15-year dichotomization of the cohort data. Because of the relative stability of the workforce and the fact that the average length of employment was 13 years, the SMR ndings for the total cohort reect nearly the same SMRs as that for the longer-term workers. Age adjustment procedures for the SMR calculations also account for length of employment because of the high correlation between age and employment duration in this cohort. Administrative/technical and management personnel generally had lower SMRs than other occupational groups, except for colon and prostate cancers, where the SMRs were slightly above 1.0 (although neither SMR was statistically signicant) (Table V). Among eld, service, linecrew, and power station workers, the results follow the same pattern as the entire cohort. Most SMRs were ,1.0 (Tables V, VI). For craft workers the SMRs for leukemias, lymphomas, and prostate cancers were slightly .1.0. Meter readers and Field services representatives (FSRs) had elevated SMRs for brain cancer and colon cancer; however, both observations were based on three observed cases and therefore had wide condence intervals (Table V). SMR analyses that focus on specic occupations (Tables V, VI) include 2,593 of the 3,211 included in the companywide SMR analysis. Occupations labeled as other or missing (Table II) were not included in the occupation-specic SMR analysis.

Internal Cohort Analysis for Selected Causes of Death


Among mortality outcomes, the most consistently elevated rate ratios were for nonintentional injuries (all injury types and motor vehicle injuries) and suicide among eld, linecrew, and craft occupations. Another consistent nding was that relative to the reference group, nearly all other occupational groups had elevated rate ratios for respiratory cancers. Management staff had ratios near 1.2 (CI, 0.71.9), whereas service, eld staff, linecrew, and power plant occupations had respiratory cancer rate ratios within a range of 1.92.5 with 95% condence intervals ranging from 1.0 (lower) to 5.0 (upper) (Table VII). All occupational groups, except management, had elevated rate ratios for all causes of death combined (range 1.321.78). These rates were driven primarily by higher rates for cardiovascular disease. All occupational groups except management and trade/craft workers, had higher rates for all cancers combined, with rate ratios within a range of 1.341.44 and all lower 95% condence limits exceeding 1.0 for service, lineman, meter readers, and plant operations occupational categories (Table VII). Management personnel had elevated rate ratios for leukemias, brain cancers, and digestive cancers [1.9 (95% CI, 0.75.4), 1.7 (95% CI, 0.46.7), and 1.8 (95% CI, 0.93.5), respectively], although all lower condence intervals were below 1.0. Most other specic cause of death ratios for this group were below or near 1.0. The highest rate ratios for lineman occupations were for all injuries and motor vehicle injuries [4.2 (95% CI 2.96.2) and 3.4 (95%

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TABLE V. Age- and Sex-Adjusted SMR Analysis for Selected Causes of Death by Occupational Category: Administrative, Management, and Service Occupations
Administrative/Technical Cause of deatha All causes Major cardiovascular All cancers Respiratory cancer Digestive cancerb Prostate cancer Lymphomas Leukemia Breast cancer c Brain cancer Colon cancer Injuries Motor vehicle injury COPD Suicide
aExcludes

Management/Professional Observed 229 103 79 23 14 8 6 6 0 3 6 5 1 3 5 SMR 0.50 0.53 0.72 0.62 0.74 1.28 0.90 1.43 0.00 0.90 0.67 0.16 0.07 0.20 0.33 95% CI 0.440.57 0.430.64 0.570.90 0.390.93 0.401.24 0.552.51 0.331.96 0.523.12 0.001.36 0.182.64 0.251.47 0.050.36 0.000.38 0.040.58 0.110.78 Observed 226 82 72 34 6 3 4 3 2 2 3 18 8 7 8

Service/Labor SMR 0.75 0.64 1.01 1.34 0.47 0.70 0.93 1.12 3.03 0.94 0.52 0.83 0.78 0.71 0.81 95% CI 0.650.85 0.510.80 0.791.27 0.931.87 0.171.03 0.142.05 0.252.39 0.233.28 0.3410.94 0.113.41 0.101.52 0.491.31 0.341.54 0.281.47 0.351.60

Observed 598 223 206 51 22 15 14 8 13 5 30 36 18 24 18

SMR 0.51 0.5 0.71 0.58 0.48 1.19 0.81 0.69 0.62 0.55 1.33 0.37 0.39 0.67 0.39

95% CI 0.470.55 0.440.57 0.620.81 0.430.76 0.300.72 0.671.97 0.441.35 0.301.37 0.331.06 0.181.29 0.901.90 0.260.51 0.230.62 0.431.00 0.230.62

death that occurred among individuals who were classied as other or missing. N 5 618. colon cancers. cAll female breast cancers, 0 male breast cancers.
bExcludes

TABLE VI. Age- and Sex-Adjusted SMR Analysis for Selected Causes of Death by Occupational Category: Field, Linecrew, and Power Station Workers
Linemen/Service appliance Cause of deatha All causes Major cardiovascular All cancers Respiratory cancer Digestive cancerb Prostate cancer Lymphomas Leukemia Breast cancerc Brain cancer Colon cancer Injuries Motor vehicle injury COPD Suicide
aExcludes

Meter reader/Field service Observed 74 25 18 7 2 0 1 1 0 3 3 12 8 1 3 SMRa 0.73 0.73 0.92 1.14 0.61 0.00 0.71 1.14 0.00 4.23 2.01 0.87 1.17 0.41 0.55 95% CI 0.570.92 0.471.08 0.551.46 0.462.35 0.072.22 0.003.82 0.013.97 0.016.32 0.0011.46 0.8512.35 0.405.88 0.451.52 0.502.30 0.012.28 0.111.59

Plant operations Observed 333 130 103 44 12 4 9 3 0 3 16 37 21 9 13 SMRa 0.72 0.65 0.98 1.21 0.64 0.57 1.40 0.74 0.00 0.99 1.86 1.08 1.32 0.57 0.85 95% CI 0.640.80 0.540.77 0.801.19 0.881.62 0.331.13 0.151.47 0.642.66 0.152.16 0.005.56 0.202.89 1.073.03 0.761.49 0.822.02 0.261.08 0.451.46 Observed 506 216 144 53 18 13 8 10 0 4 16 43 29 16 19

Trade/craft SMRa 0.60 0.60 0.74 0.77 0.52 1.06 0.66 1.34 0.00 0.66 1.02 0.68 0.99 0.58 0.66 95% CI 0.550.65 0.520.68 0.630.87 0.571.00 0.310.82 0.571.82 0.291.31 0.642.47 0.0010.79 0.181.70 0.581.65 0.490.92 0.661.42 0.330.94 0.401.03

Observed 627 217 195 76 25 18 18 9 1 4 12 90 35 22 22

SMRa 0.68 0.58 0.96 1.07 0.70 1.49 1.37 1.08 3.57 0.60 0.74 1.09 0.89 0.79 0.61

95% CI 0.630.74 0.500.66 0.831.11 0.841.33 0.451.03 0.882.35 0.812.17 0.492.06 0.0519.87 0.161.53 0.381.30 0.871.34 0.621.24 0.491.20 0.380.92

deaths that occurred among individuals who were classied as other or missing. N 5 618. colon cancers. cAll female breast cancers, 0 male breast cancers.
bExcludes

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TABLE VII. Internal Cohort Analysis for Selected Causes of Death by Occupational Category, 19601991
Management/ Professional Mortality outcome All causes Major cardiovascular All cancers Respiratory cancer Digestive cancerd Prostate cancer Lymphomas Leukemia Breast cancere Brain cancer Colon cancer Injuries Motor vehicle injury COPD Suicide
aExcludes bMantel

Meter reader/ Service/Labor mRRa,b,c 1.59 1.48 1.44 2.64 1.21 0.77 1.28 1.55 0.65 1.60 0.40 2.76 2.63 1.20 2.23 95% CI 1.371.86 1.151.91 1.101.89 1.714.07 0.483.04 0.222.66 0.423.94 0.435.61 0.142.92 0.327.98 0.121.32 1.574.83 1.136.09 0.522.77 0.965.20 Linemen mRRa,b,c 1.57 1.42 1.41 2.19 1.73 1.67 1.96 1.66 0.13 1.26 0.59 4.24 3.36 1.28 2.03 95% CI 1.411.76 1.181.71 1.161.71 1.543.12 0.973.07 0.843.31 0.973.99 0.654.24 0.020.89 0.354.50 0.301.14 2.896.22 1.905.94 0.722.30 1.093.76 Field service mRRa,b,c 1.78 1.71 1.34 2.25 1.25 0.96 1.93 10.19 1.53 3.49 4.26 0.59 2.01 95% CI 1.392.28 1.132.58 0.822.18 1.015.00 0.295.36 0.118.51 0.2515.05 2.3144.96 0.455.21 1.806.76 1.849.85 0.084.23 0.567.14 Plant operations mRRa,b,c 1.58 1.56 1.40 2.39 1.63 0.60 2.12 0.98 1.78 1.38 3.91 4.68 0.91 2.65 95% CI 1.391.81 1.261.94 1.111.78 1.603.58 0.823.26 0.201.81 0.914.90 0.263.66 0.437.32 0.742.56 2.486.16 2.478.89 0.431.95 1.265.54 Trade/craft mRRa,b,c 1.32 1.44 1.07 1.55 1.28 1.18 0.95 1.83 1.36 0.81 2.48 3.55 0.97 1.98 95% CI 1.171.49 1.191.73 0.861.32 1.052.28 0.682.43 0.562.48 0.392.30 0.724.62 0.404.59 0.451.48 1.603.83 1.976.39 0.521.82 1.033.82

mRRa,b,c 1.02 1.19 1.01 1.17 1.76 1.25 1.22 1.89 1.66 0.52 0.46 0.21 0.31 0.91

95% CI 0.881.19 0.941.50 0.781.31 0.711.91 0.893.46 0.532.96 0.463.23 0.665.41 0.416.66 0.221.24 0.181.22 0.031.62 0.091.02 0.332.47

801 year olds. Haenszel summary rate ratios (age- and sex-adjusted). cReference groupadministrative/technical/clerical occupations (see Table IV for number of events in each occupational group). dExcludes colon cancers. eFemales only, no male breast cancers observed.

CI 1.95.9), respectively]. In addition to respiratory cancers, among lineman occupations, specic cancers that had rate ratios .1.5 included lymphomas, prostate, digestive, and leukemia. Meter reader and eld services occupations had higher ratios for brain cancer and leukemia. Plant operator occupations had elevated rate ratios for lymphomas and digestive cancers. In addition to respiratory cancer, trade and craft occupations had elevated leukemia rates; however, most other cancer rate ratios were near 1.0. For each of the seven occupational categories, we divided the workers into two groups: those active as of January 1, 1960 (the start date of our cohort denitions) and those active after January 1, 1960. We then calculated rate ratios relative to the administrative/technical classication. The rationale for these analyses was that the survivor cohort as of 1960 may be different than the workers starting after 1960. We present data for selected occupational categories (service/labor, linemen, and trade/craft) where we had sufficient numbers of workers and death events to conduct these analyses (Table VIII). For the most part, the overall results are closer to the subcohort who were active workers as of January 1, 1960. This is because most of the death events occurred among these workers. In comparing rate ratios between the active as of 1960 subcohorts and the active after 1960 subcohorts, we generally observed higher

rate ratios in the latter group, although none of these differences is statistically signicant.

DISCUSSION
These SMR ndings emphasize the improved health status among a stable, nancially secure worker population with adequate access to health care. When comparing the entire electric utility cohort or specic occupational groups to the general population, the SMRs were #1.0 for nearly all mortality outcomes. This result has four components to consider. First, there is some degree of organizational and self-selection into the cohort. Second, continued membership in the workforce may be differential by underlying health status. Taken together, these represent the healthy worker effect [Howe et al., 1988; Arrigi and HertzPicciotto, 1994; Wen and Tsai, 1982; Wilcosky and Wing, 1987]. As a measure of the strength of the healthy worker effect, COPD mortality can be used as an indicator of selection for good health status [Park et al., 1991]. For this electric utility cohort, the SMRs for COPD and cardiovascular disease for all workers and all occupational groups were low, indicating a strong healthy worker effect. Third, the cohort may have different personal exposures than the general population in areas like diet, exercise, alcohol

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TABLE VIII. Cohort Analyses for Selected Occupational Groups by Work Status as of 1960
Service/Labor Active before 1960 Cause of deatha All causes Major cardiovascular All cancers Respiratory cancer Digestive cancerb Prostate cancer Lymphomas Leukemia Breast cancerc Brain cancer Colon cancer Injuries Motor vehicle injury COPD Suicide
aExcludes

Linemen Active before 1960 RR 1.37 1.28 1.33 1.82 1.78 1.50 1.98 1.28 0 0.99 0.39 3.02 4.32 1.27 1.50 95% CI 1.201.55 1.041.56 1.061.67 1.222.70 0.883.58 0.753.02 0.894.41 0.423.87 0.195.17 0.180.85 1.555.89 1.2215.30 0.692.32 0.573.97 Active after 1960 RR 2.00 0.52 1.63 4.22 1.30 0 0.55 3.81 0.47 2.99 3.13 5.19 3.49 0 2.43 95% CI 1.542.58 0.191.39 1.012.60 1.5911.20 0.414.13 0.064.94 0.3640.60 0.054.37 0.1368.90 0.8212.00 3.158.56 1.766.92 1.005.90

Trade/Craft Active before 1960 RR 1.23 1.36 1.06 1.40 1.45 0.87 1.03 1.85 0 0.90 0.61 0.88 1.77 0.94 2.26 95% CI 1.061.41 1.111.66 0.821.35 0.912.15 0.693.03 0.391.97 0.382.75 0.665.22 0.165.18 0.311.22 0.362.15 0.388.18 0.481.82 0.895.77 Active after 1960 RR 1.48 1.28 1.05 1.95 0.82 8.39 0.48 1.22 0 2.51 1.97 3.83 4.40 0.71 1.63 95% CI 1.161.87 0.752.17 0.681.62 0.814.72 0.223.05 0.9673.60 0.054.14 0.1212.0 0.3716.91 0.527.48 2.286.43 2.328.34 0.077.19 0.634.19

Active after 1960 RR 1.80 2.00 1.71 3.92 2.08 4.68 2.00 3.70 0.40 1.57 0 2.57 2.00 2.82 2.94 95% CI 1.372.34 1.183.39 1.112.63 1.788.62 0.518.37 0.4251.64 0.3611.10 0.6122.50 0.043.61 0.1813.40 1.112.63 0.755.31 0.4417.92 0.998.76

RR 1.58 1.44 1.30 2.34 0.67 0.30 1.10 0.74 0.98 1.58 0.54 3.34 5.44 1.10 1.44

95% CI 1.311.91 1.071.94 0.911.86 1.364.02 0.153.00 0.042.37 0.235.13 0.096.04 0.118.28 0.1615.40 0.161.82 1.388.12 1.0827.40 0.422.90 0.316.82

801 year olds. colon cancers. cFemales only, no male breast cancers observed.
bExcludes

consumption, or cigarette smoking. Fourth, with respect to occupational exposures in this industry, there may be few exposure effects on health. It is possible that for disease outcomes where the SMRs are near 1.0, there may be some exposure health effects that are masked by the healthy worker selection biases. Internal cohort analyses provide an alternative reference group instead of the general population that reduces differences in employment status and the provision of health care. Accounting for both of these factors helps to reduce the potential bias due to the healthy worker effect [Park et al., 1991; Wen and Tsai, 1982; Wilcosky and Wing, 1987]. We used the occupational group with the lowest SMRs (administrative/technical personnel) as the reference group in the internal cohort analyses. This created numerous elevated rate ratio estimates among the other occupational groups. Our internal cohort analyses revealed substantial variation in mortality risk between occupational groups. These variations may be attributable to three components. First, there are likely selection factors that inuence the composition of these occupational groups. This is synonymous to the healthy worker effect when comparing our working cohort to the general population. Our ndings for the separate analyses of workers active as of 1960 versus workers active after 1960 suggest a healthy survivor effect occurring in this cohort, because the early subcohorts had, in general, lower rate ratios than the latter group. However, these analyses are

limited by small numbers. Second, life-style choices and social, economic, and cultural inuences are likely to vary by occupational group. Third, work-related exposures will also be different. Consistently higher respiratory cancer among nonoffice employees highlights the need for additional research on the occurrence of cigarette smoking and workplace exposures potentially associated with these type of cancers (e.g., asbestos, airborne solvent exposures, dust and particulate exposures, and other workplace exposures). Although we observed consistent elevated rate ratios for respiratory cancer, the exposures across these groups can vary widely. In addition, when we compared smoking history between occupations, we observed some variation. However, we did not observe excess mortality due to COPD, which has been used as a proxy for smoking history. The rate ratios for leukemia, which has been associated with benzene, solvent, ionizing radiation and magnetic eld exposures, were inconsistent (Gilbert and Marks, 1979; The riault et al., 1994). They were higher among occupations with low exposure levels to these agents (managers and meter readers) and lower among plant operations occupations, who probably have higher exposures to these agents. Lineman and trade/craft occupations had moderately higher rate ratios for leukemias. For lymphomas, a cancer also associated with many of these agents, there were higher rate ratios (near 2.0) for lineman and plant operations occupations, yet a low ratio among trade/craft occupations.

Mortality Among a Cohort of Electric Utility Workers

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A consistent association was found between mortality outcomes and occupation for nonintentional injuries, particularly motor vehicle injuries. Nonoffice occupations had rate ratios within a range of 2.64.7 for motor vehicle injuries. Fatal motor vehicle injuries while performing company duties are rare and do not account for these differences. The SMRs for injuries indicate lower risk than for the general population, and this has been the nding among most mortality analyses of occupational cohorts. However, few studies have examined within-cohort variation for the risk of fatal injuries. A recently completed study among Canadian utility workers found elevated rate ratios for mortality due to nonintentional injury and violence among those workers with higher exposures to electric elds [Baris et al., 1996a]. This classication of Canadian workers includes several of the nonoffice occupations in the Edison cohort; however, our analyses are not based on electric or magnetic eld exposure classication, but rather on job titles (usual occupation). Factors associated with some of these occupations such as shiftwork, overtime work, and fatigue may contribute to the increased risk of nonwork fatal injuries. However, preliminary analysis of work-related injury data has not suggested increased injury risk for shift workers or work during time of disaster response (unpublished data). Other personal factors such as increased recreational driving for certain occupational groups or different alcohol consumption patterns may also explain these differences. Self-reported alcohol consumption data, obtained from a sample of the current workforce, did not vary across occupational groups in a pattern similar to the injury mortality rates. These survey data although useful, are limited by low response, the fact that they are group (ecological) rather than individual data and represent behaviors by the current workforce, not necessarily the historical cohort. Alcohol consumption self-reporting may also vary by occupation, with certain groups more likely to underreport their consumption patterns. Our mortality ndings may also be driven by an unusually low injury fatality rate among the comparison group, administrative/technical office workers. These factors should be evaluated in future case-control studies. Another noncancer outcome that was consistently associated with nonoffice occupations was suicide. Risk factors for suicide include marital status, age, sex, and depression. In a study that evaluated the relationship between magnetic elds and depression, Savitz and colleagues found that the prevalence of depression among electrical workers was not elevated when compared to nonelectrical workers, although there was a suggestion of increased prevalence among one subgroup, electricians [Savitz et al., 1994]. Among Canadian utility workers, there was an increase risk of suicide observed in relation to electric eld exposures; however most exposure indices did not suggest an association. Also, the dose-

response trends were not consistent and the study was limited by a small sample size [Baris et al., 1996b]. We have previously reported results for all cancers combined, leukemias, lymphomas, and brain cancers and their relation to power frequency magnetic elds [Sahl et al., 1993]. The ndings presented in this analysis are somewhat different due to several factors. First, we have expanded the cohort to include three additional years of follow-up. Second, we used a revised occupational classication system; and third, our reference group in the latest analyses was dened as administrative, technical and clerical staff without any regard to magnetic eld exposures. In our magnetic eld exposure and cancer analyses, the reference group included service/labor and meter reader occupational groups, which have higher rate ratios for several cancer and noncancer mortality outcomes. The lower mortality rate in the current reference group compared to our rst reference group produced higher relative ratio results. The limitations of the study include the use of job titles instead of developing a series of specic job exposure matrices. In addition, we have only selected the usual occupation to represent the workers occupational history. All these job title/cancer outcome associations are also limited by low study power and potential exposure misclassication. Future analyses will focus on specic exposures, and cumulative exposure scores will be developed using job exposure matrices and the workers complete occupational history. Although we provide some information on smoking patterns and alcohol consumption in the current workforce, direct individual information and other confounding information was not available. The mortality experience of this electric utility cohort may be unique and not represent the experience of other electric utility groups. We did not observe an excess of breast cancer as previously reported (Loomis et al., 1994). However, these ndings are consistent with the SMR results of a cohort of 138,905 male electric utility workers selected from ve U.S. electric utility companies [Savitz and Loomis, 1995] and 21,744 male Canadian electric utility workers [Baris et al., 1996a] and with cancer mortality among Scandinavian utility workers [Tornquist et al., 1986]. The main purposes of this overall mortality analysis were (1) to assess whether any major health hazards were present in this cohort of workers, and (2) to use the mortality ndings as a guide in developing more targeted research that focuses on the potential relationships of mortality outcomes and specic exposures in community, personal, and work environments. Despite the limitations in this design and analysis, our ndings suggest that relative to the general Southern California population, this workforce has lower overall mortality, less cardiovascular disease and cancer, and lower mortality rates due to nonintentional injury. These ndings are consistent with many occupational studies that

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compare their workers mortality experience to that of the general population. Our ndings highlight the substantial variation in mortality risk across different occupational groups within the same industry. The higher rates of respiratory cancer, nonintentional injuries, and suicide among nonoffice occupational groups merit further research on both occupational and nonoccupational factors. If these associations persist across different studies, further research of specic exposures in these groups is warranted.

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ACKNOWLEDGMENTS
The authors acknowledge the valuable contributions of Delia Garnes, Rick Sands, Karen Haines, Dena Sherick, and Carolyn Watkins for their work in project administration, data programming, manuscript preparation, and data coding. Funding was provided by the Southern California Edison Company, Health Research and Evaluation Division.

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