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Volume 156
Issue 8
15 October 2002


ARTICLE CONTENTS

 * Abstract
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ASSOCIATION BETWEEN CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND EMPLOYMENT BY
INDUSTRY AND OCCUPATION IN THE US POPULATION: A STUDY OF DATA FROM THE THIRD
NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY

Eva Hnizdo,
Eva Hnizdo
From the Division of Respiratory Disease Studies, National Institute for
Occupational Safety and Health, Centers for Disease Control and Prevention,
Morgantown, WV.
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Patricia A. Sullivan,
Patricia A. Sullivan
From the Division of Respiratory Disease Studies, National Institute for
Occupational Safety and Health, Centers for Disease Control and Prevention,
Morgantown, WV.
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Ki Moon Bang,
Ki Moon Bang
From the Division of Respiratory Disease Studies, National Institute for
Occupational Safety and Health, Centers for Disease Control and Prevention,
Morgantown, WV.
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Gregory Wagner
Gregory Wagner
From the Division of Respiratory Disease Studies, National Institute for
Occupational Safety and Health, Centers for Disease Control and Prevention,
Morgantown, WV.
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American Journal of Epidemiology, Volume 156, Issue 8, 15 October 2002, Pages
738–746, https://doi.org/10.1093/aje/kwf105
Published:
15 October 2002

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   Eva Hnizdo, Patricia A. Sullivan, Ki Moon Bang, Gregory Wagner, Association
   between Chronic Obstructive Pulmonary Disease and Employment by Industry and
   Occupation in the US Population: A Study of Data from the Third National
   Health and Nutrition Examination Survey, American Journal of Epidemiology,
   Volume 156, Issue 8, 15 October 2002, Pages 738–746,
   https://doi.org/10.1093/aje/kwf105
   
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ABSTRACT

Data from the US population-based Third National Health and Nutrition
Examination Survey, conducted from 1988 to 1994, were used to estimate the
population prevalence, prevalence odds ratios, and attributable fractions for
the association of chronic obstructive pulmonary disease (COPD) with employment
by industry and occupation. The aim was to identify industries and occupations
at increased risk of COPD. COPD was defined as forced expiratory volume in 1
second (FEV1)/forced vital capacity <70% and FEV1 <80% predicted. The authors
used SUDAAN software (Research Triangle Institute, Research Triangle Park, North
Carolina) to estimate the weighted population prevalence and odds ratios using
9,823 subjects aged 30–75 years who underwent lung function tests. Odds ratios
for COPD, adjusted for age, smoking status, pack-years of smoking, body mass
index, education, and socioeconomic status, were increased for the following
industries: rubber, plastics, and leather manufacturing; utilities; office
building services; textile mill products manufacturing; the armed forces; food
products manufacturing; repair services and gas stations; agriculture; sales;
construction; transportation and trucking; personal services; and health care.
Occupations associated with increased odds ratios for COPD were freight, stock,
and material handlers; records processing and distribution clerks; sales;
transportation-related occupations; machine operators; construction trades; and
waitresses. The fraction of COPD attributable to work was estimated as 19.2%
overall and 31.1% among never smokers.

airway obstruction; occupational diseases; occupational exposure; prevalence
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary
disease; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity;
NHANES III, Third National Health and Nutrition Examination Survey; OR, odds
ratio; RR, relative risk.
Topic:
 * smoking
 * chronic obstructive airway disease
 * employment
 * national health and nutrition examination survey

Issue Section:
ORIGINAL CONTRIBUTIONS

Received for publication November 21, 2001; accepted for publication May 28,
2002.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of
death among persons older than 45 years of age in the United States (1).
Occupational exposure is a known risk factor for COPD. Industry-based
epidemiologic studies have shown that occupational exposure to inorganic and
organic dusts and to chemical agents can increase the risk of COPD (2–4). In
addition, general population-based studies have identified associations between
COPD and employment in industrial and job categories or specific occupational
exposures (5–16). However, to our knowledge, the contribution of occupational
exposure to COPD morbidity in the general US population has not yet been
quantified. The population-based Third National Health and Nutrition Examination
Survey (NHANES III) (17, 18) enables estimation of the population prevalence and
prevalence odds ratios for COPD and employment by industry as well as evaluation
of the magnitude of the effect of occupational exposure on COPD in the US
population (19).

The objective of the present study was to analyze the NHANES III survey data to
estimate the prevalence, prevalence odds ratios, and attributable fractions for
COPD and employment by specific industry sectors (industry) and occupational
categories (occupation). The aim was to estimate the magnitude of the effect of
occupational exposure on COPD in the US population and to identify industries
and occupations at increased risk of COPD that can be targeted for etiologic
studies or disease prevention programs.


MATERIALS AND METHODS


STUDY SUBJECTS

The NHANES III survey was conducted from 1988 to 1994 by the National Center for
Health Statistics in Hyattsville, Maryland, to assess the health and nutritional
status of the US population. A multistage, stratified probability sampling
design was used to select a representative sample of the US adult population
aged 17–90 years (17). African Americans, Mexican Americans, and persons aged 60
years or older were oversampled. Eighty-one counties in the United States were
sampled; in each county and selected household, the probability of a person
being chosen was based on sex, age, and race/ethnicity. The resulting total
sample of 20,050 adult subjects aged 17 years or older included 47 percent
females and 53 percent males; 42.3 percent were Caucasian, 27.4 percent were
African American, and 26.5 percent were Mexican American. The survey included a
questionnaire, a laboratory examination, and lung function testing.

The present study included subjects aged 30–75 years (n = 11,447). These age
cutoff points were chosen under the assumption that COPD due to occupational
exposure would not generally be observed before midlife (20). In addition, many
subjects less than age 30 years are still reaching their full lung function
potential (21), and many older subjects develop age-related medical conditions
that can affect lung function. Furthermore, we excluded 1,009 subjects because
of lung function testing problems (missing tests (n = 826), unreliable flow
volume curves (n = 97), or only one reliable maneuver (n = 86)), 506 subjects
with physician-diagnosed current asthma, and 109 subjects for whom occupational
codes were missing, leaving 9,823 subjects for the data analysis.


DEFINITION OF COPD

The definition of COPD was based on Global Initiative for Chronic Obstructive
Lung Disease (GOLD) working group criteria (20) of forced expiratory volume in 1
second (FEV1)/forced vital capacity (FVC) less than 70 percent and FEV1 less
than 80 percent predicted. The FEV1 percent predicted values were calculated by
using sex-specific reference equations for Caucasians, African Americans, and
Mexican Americans, estimated from tests of asymptomatic nonsmokers in the NHANES
III study (21). Lung function testing methods for the NHANES III study conformed
to the 1987 American Thoracic Society acceptability and reproducibility criteria
(22).


CIGARETTE SMOKING

The NHANES III survey included questions on current smoking status, number of
cigarettes smoked, and age at which smoking started and stopped. Two smoking
variables were created: smoking status and pack-years. For smoking status,
subjects were categorized as never smokers, former smokers, or current smokers.
Pack-years were estimated by multiplying the current number of packs of
cigarettes smoked (or, for former smokers, the number of packs smoked when they
last smoked) by the number of years of smoking. Never smokers were defined as
those who smoked fewer than 100 cigarettes during their entire life.


OCCUPATIONAL CODING

Occupational coding was based on two items on the NHANES III Adult Survey
Questionnaire. That is, study subjects were asked to identify 1) the type of
work they performed for the longest period of time (occupation) and 2) for this
occupation, the type of business or industry they worked in the longest
(industry). In the NHANES III data set, occupation was coded according to the
1990 Occupational Classification System used in the 1990 US Census (23). These
codes were derived from the 1980 Standard Occupational Classification codes
published by the US Department of Commerce (24). Industry was coded according to
the 1990 Industrial Classification System used in the 1990 US Census, a
modification of the Standard Industrial Classification codes (25). These
detailed industry and occupation codes are collapsed in the NHANES III public
use data set.


INDUSTRY CATEGORIES USED IN THE ANALYSIS

The NHANES III data set contains 44 industry and 40 occupation codes that
include workers with a varied potential for exposure to respiratory hazards. A
priori, we grouped industries in which workers had a similar potential for
exposure to respiratory hazards believed to cause COPD as follows. We kept the
original industry categories, but subjects with office work occupations were
excluded from the industrial sectors. Office workers from all industry sectors
were combined into a single category that was used as a comparison group. This
“office workers” category included managers, secretaries and typists, clerks,
and administrative workers as well as teachers, writers and artists,
professionals, and workers from such nonmanufacturing sectors as banking,
insurance, communications, education, social service, and public administration.
We moved laborers, cleaners, material handlers, and maintenance workers from the
banking, insurance, communications, education, social service, and public
administration sectors into a new industry category called “office building
services.” Similarly, we moved construction, horticultural, medical, food
preparation, and transportation workers from the nonmanufacturing sectors to the
appropriate industry category with a similar potential for exposure to
respiratory hazards.

This recoding resulted in 26 industry categories. For the final analysis, we
combined categories in which odds ratios for COPD were not increased into one
category of “other industries,” which resulted in 16 final categories for the
overall analysis.


OCCUPATION CATEGORIES USED IN THE ANALYSIS

The NHANES III data set includes 40 occupation codes combined across all
industries. A priori, we collapsed them into 25 occupational categories believed
to have a similar potential for exposure to respiratory hazards and sufficient
numbers for analysis. For the final analysis, occupational categories for which
there was no evidence of an increased risk of COPD were combined in an “other
occupations” category, resulting in 14 final categories.


STATISTICAL DATA ANALYSIS

We used the SUDAAN software program (26) to estimate the weighted population
size, prevalence, and prevalence odds ratios for COPD by industry and
occupation. This software adjusts for the sampling design in calculating the
variance estimates (27) and uses individual sampling weights assigned by the
National Center for Health Statistics to adjust for the number of persons in the
population that each sampled person represents. The weighted estimates are
unbiased estimators of the US population parameters (19).

The SUDAAN logistic program was used to estimate odds ratios for COPD and
industry/occupation adjusted for the effect of age, sex, race/ethnic group, body
mass index, smoking status, pack-years of cigarette smoking, education, and
socioeconomic status (20). Socioeconomic status was adjusted by using the
poverty income index, computed as the ratio of the family income and the poverty
threshold value specific to the family size. Industry (or occupation) was
included in the models as a set of 0 or 1 dummy variables representing each
industry (or occupation). Because of large numbers and a low prevalence of COPD,
office workers were used as the baseline category against which other
occupational groups were compared. Preliminary analyses revealed differences
between sexes and among race/ethnic groups in the size of the adjusted odds
ratios; therefore, we also conducted sex- and race/ethnic-specific analyses for
COPD to better identify subgroups at risk of COPD.

In an unweighted analysis, we examined trends in adjusted odds ratios for COPD
and increasing duration of employment in the longest-held occupation
(ascertained by asking the following question: Considering all your employers,
for how long did you do this kind of work?). For that purpose, occupations were
grouped, according to the size of the estimated odds ratio for COPD, into high-
and low-risk groups. In these groups, the trend with duration of employment (0,
1–14, ≥15 years) was estimated by using office workers as the “unexposed”
comparison group.

The population attributable fraction (AFP; i.e., the fraction of cases with COPD
due to industrial exposure) was calculated according to the following formula
(28–30):

(ORi – 1)/ORi

where k = number of industry sectors; pci = casesi/total cases, where casesi
represents the estimated number of COPD cases in the ith industry and total
cases represents the total number of cases summed across industry sectors; and
ORi = the adjusted odds ratio for COPD estimated for the ith industry.


RESULTS

Of the 9,823 subjects aged 30–75 years for whom lung function tests were valid,
693 (7.1 percent) were identified as having COPD. To assess disease severity, we
compared mean percent predicted FEV1, mean percent predicted FVC, and FEV1/FVC
ratio for subjects without COPD, with COPD, and with physician-diagnosed
emphysema or chronic bronchitis reported on the NHANES III questionnaire (table
1). In table 1, subjects with COPD defined epidemiologically had lower mean lung
function values than those with physician-diagnosed emphysema or those with
chronic bronchitis.

Table 2 shows the distribution of all study subjects and never smokers according
to nonoccupational risk factors for COPD that were adjusted for in the logistic
regression. Table 2 also shows the population prevalence of COPD according to
these factors.


COPD BY INDUSTRIAL SECTORS

The overall analysis identified 14 industries with increased adjusted odds
ratios for COPD. Table 3 shows the estimated numbers of US workers employed in
these industries, the estimated prevalence of COPD, the sample size, the number
of observed cases with COPD, and the adjusted odds ratios and 95 percent
confidence intervals for COPD for all subjects and for never smokers. The “other
industries” category combines industries for which the overall odds ratios were
not increased.

The results for never smokers provided supporting evidence for the overall
results. Although the overall odds ratios for some of the industries shown in
table 3 were low, results from the sex- and race/ethnic-specific analyses
identified subgroups with a higher risk of COPD and provided further supporting
evidence for the overall results.

The sex-specific analyses showed that for females, the adjusted odds ratios for
COPD (number of cases/number of subjects exposed) were increased for rubber,
plastics, and leather manufacturing overall (8/46; OR = 4.7, 95 percent
confidence interval (CI): 2.7, 8.3) and for never smokers in that industry
(2/31; OR = 3.8, 95 percent CI: 1.2, 12.3); for the textile mill products
manufacturing industry overall (10/99; OR = 2.4, 95 percent CI: 1.2, 4.8) and
for never smokers in that industry (3/53; OR = 6.0, 95 percent CI: 0.6, 62); for
the agriculture industry overall (13/196; OR = 2.0, 95 percent CI: 0.9, 4.5) and
for never smokers in that industry (6/134; OR = 2.3, 95 percent CI: 0.5, 10.4);
for sales overall (40/512; OR = 1.6, 95 percent CI: 0.9, 2.9) and for never
smokers in that industry (8/279; OR = 3.0, 95 percent CI: 0.7, 13); for food
products manufacturing overall (9/123; OR = 1.5, 95 percent CI: 0.6, 4.0) and
for never smokers in that industry (2/77; OR = 3.4, 95 percent CI: 0.3, 44); and
for personal services overall (34/470; OR = 1.5, 95 percent CI: 0.7, 3.2). For
the rubber, plastics, and leather manufacturing industry, the detailed analysis
showed that occupations in this industry contributing the most cases were
textile apparel machine operators as well as fabricators and assemblers. For
sales, a detailed analysis showed that the adjusted odds ratios were increased
for Caucasian females (34/285; OR = 1.9, 95 percent CI: 1.0, 3.5).

Industries presented in table 3 that employed mainly males were utilities, the
armed forces, repair services and gas stations, and transportation and trucking.
However, use of the male office workers group as a referent resulted in odds
ratios for COPD similar to those reported in table 3. The prevalence of COPD
among the male referent group was 5.1 percent (standard error, 0.9); for the
overall referent group, it was 4.7 percent (standard error, 0.4).

Race/ethnic-specific adjusted odds ratios for COPD for Caucasians were similar
to the overall odds ratios shown in table 3. Industries associated with
increased adjusted odds ratios for COPD (number of cases/number of subjects
exposed) mainly for African Americans and Mexican Americans were office building
services, agriculture, and construction (office building services—African
Americans: 6/48; OR = 2.9, 95 percent CI: 0.8, 10.6; Mexican Americans: 4/24; OR
= 2.1, 95 percent CI: 0.4, 9.9; agriculture—African Americans: 14/76; OR = 2.1,
95 percent CI: 0.9, 5.1; Mexican Americans: 22/339; OR = 1.8, 95 percent CI:
0.7, 4.6; construction—African Americans: 15/140; OR = 1.6, 95 percent CI: 0.7,
3.6; Mexican Americans: 9/160; OR = 1.6, 95 percent CI: 0.5, 5.9). Industries
for which the odds ratios were increased mainly for Mexican Americans were
personal services (15/161; OR = 2.7, 95 percent CI: 0.8, 9.7) and health care
(4/118; OR = 3.7, 95 percent CI: 1.3, 10.7). The personal services industry
included hairdressers and cosmetologists.


COPD BY OCCUPATIONAL CATEGORIES

The overall analysis identified 12 occupational categories with increased odds
ratios for COPD. Table 4 shows the estimated number of US workers employed in
these occupations, the prevalence of COPD, the sample size, the number of cases
with COPD, and the adjusted odds ratios and 95 percent confidence intervals for
COPD for all subjects and for never smokers. Occupations for which there was no
evidence of increased odds ratios were combined into an “other occupations”
category. An occupational category generally included workers from several
industries, but some occupational categories were similar to industries (the
armed forces and agriculture) and were included for completeness. Occupations
that had the highest odds ratios were freight, stock, and material handlers; the
armed forces; vehicle mechanics; and records processing and distribution clerks.
In addition, among never smokers, the odds ratios were also high for other
machine operators and for construction trades and laborers.

Results from the race/ethnic-specific analyses identified subgroups with a
higher risk of COPD and, although based on small numbers, showed a degree of
consistency. For Caucasians, the odds ratios for COPD (number of cases/number of
subjects exposed) were similar to the overall results, but they were
specifically increased for the occupations of records processors, schedulers,
and distribution clerks (23/180; OR = 1.8, 95 percent CI: 0.8, 4.4); sales:
retail and personal services (43/333; OR = 1.7, 95 percent CI: 0.9, 3.1); and
other machine operators (25/178; OR = 1.6, 95 percent CI: 0.8, 3.2). For African
Americans and Mexican Americans, the odds ratios were higher for agriculture and
construction, as reported for the industries. For the armed forces, the odds
ratios were increased for all three race/ethnic groups: Caucasians (7/53; OR =
1.5, 95 percent CI: 0.5, 4.3), African Americans (5/42; OR = 2.1, 95 percent CI:
0.7, 6.2), and Mexican Americans (2/12; OR = 1.7, 95 percent CI: 0.1, 20.8). For
vehicle mechanics, the odds ratios were also increased for all three race/ethnic
groups: Caucasians (9/66; OR = 2.1, 95 percent CI: 0.8, 5.2), African Americans
(3/25; OR = 3.8, 95 percent CI: 0.8, 17.3), and Mexican Americans (2/46; OR =
2.0, 95 percent CI: 0.3, 14.5). For transportation and material moving, the
increased odds ratios were observed mainly for Caucasians (8/44; OR = 1.6, 95
percent CI: 0.7, 3.9) and African Americans (7/55; OR = 1.7; 0.6, 4.8).


ATTRIBUTABLE FRACTION FOR COPD

The overall attributable fractions for industry and occupation were calculated
from equation 1 by using the estimated population size, prevalence, and adjusted
odds ratios provided in table 3 and table 4. No cases were attributed to
industries in which ORi ≤ 1.

For each industry, table 3 shows the number of attributable cases. The total
estimated working population aged 30–75 years was 110,300,000. Of these persons,
7,652,390 (6.9 percent) were estimated to have COPD. The number of cases
attributable to employment in industries, after adjustment for confounding, was
1,467,290, resulting in an attributable fraction of 1,467,290/7,652,390 × 100 =
19.2 percent. We also estimated the overall adjusted odds ratio for COPD and the
14 industries with OR > 1 grouped into one category as 1.5 (95 percent CI: 1.1,
2.0). Based on this odds ratio, the attributable fraction was estimated to be
19.6 percent (95 percent CI: 7.0, 28) (31). For never smokers, the estimated
working population was 46,490,000, of whom 1,131,840 (2.4 percent) were
estimated to have COPD. The number of attributable cases was 352,167, which
resulted in an attributable fraction of 31.1 percent. For never smokers, the
overall odds ratio for COPD and the industries with OR > 1 grouped into one
category was 1.9 (95 percent CI: 0.9, 4.1), and the attributable fraction was
estimated as 27.8 percent (95 percent CI: 1.0, 47).

For each occupation, table 4 shows the number of attributable cases. The number
of cases of COPD attributable to employment by occupation was 1,150,900 of
7,642,230 total cases, resulting in an attributable fraction of 15.1 percent.
(Thirty-three subjects for whom there was no job code were excluded, resulting
in a slightly different weighted total number of cases from the industry.) The
overall adjusted odds ratio for occupations with OR > 1 grouped into one
category was 1.4 (95 percent CI: 1.0, 2.0), and the corresponding attributable
fraction was estimated as 15.1 percent (95 percent CI: 3.4, 25.8). For never
smokers, the number of attributable cases was 307,299 of 1,123,370 total cases,
resulting in an attributable fraction of 27.4 percent. The overall adjusted odds
ratio for occupations with OR > 1 grouped into one category was 2.1 (95 percent
CI: 0.9, 5.0), and the attributable fraction was 25.6 percent (95 percent CI:
2.3, 28.5). Because the occupations were summed over industries and some of the
industries with increased odds ratios were not represented by the occupational
categories with increased risk, the attributable fractions for the occupations
were lower than those for the industry.


TRENDS WITH DURATION OF EMPLOYMENT

The average duration of working in the longest-held occupation was 15.9
(standard error, 0.1) years. For the high-risk occupations (for all subjects, OR
≥ 1.5) shown in table 4, the odds ratios for COPD by duration of employment—0,
1–14, and ≥15 years—were 1.0, 1.4 (95 percent CI: 0.8, 2.6), and 1.7 (95 percent
CI: 1.1, 2.5), respectively. The greatest trend was observed among the armed
forces, where the respective odds ratios were 1.0, 1.4 (95 percent CI: 0.3,
6.1), and 2.0 (95 percent CI: 1.0, 4.0). For the lower-risk occupations (for all
subjects, 1 < OR < 1.5) shown in table 4, the respective odds ratios were 1.0,
1.4 (95 percent CI: 1.0, 1.9), and 1.5 (95 percent CI: 1.2, 2.0). The results
suggest a trend associated with working 15 or more years in risky occupations.


DISCUSSION

A recent study that estimated the cost of occupational COPD in the US population
assumed that 15 percent of deaths from COPD is attributable to occupational
exposure (32). The overall cost for occupational COPD was estimated to be $5
billion in 1996 (32). The present study estimated that 19 percent (approximate
95 percent CI: 7, 28) of COPD in the US working population aged 30–75 years is
attributable to occupational exposure. For never smokers, the attributable
fraction was estimated as 31 percent (approximate 95 percent CI: 1, 47).

The present study generated hypotheses aimed at 1) identifying industries
associated with an increased risk of COPD that might be targeted for further
research and 2) estimating the attributable fraction for occupational COPD. The
estimated attributable fraction of 19 percent was based on increased odds ratios
for COPD in 14 industries listed in table 3. Additional supporting evidence for
an increased risk of COPD in these industries came from increased odds ratios
for never smokers, for sex- and race/ethnic-specific sub- groups, and by
occupational categories. In preliminary analyses in which a less stringent
cutoff point of 75 percent was used for the FEV1/FVC ratio, we observed a higher
degree of consistency among the three major race/ethnic groups for the adjusted
odds ratios for industries and occupations. Use of Global Initiative for Chronic
Obstructive Lung Disease criteria resulted in a reduced number of COPD cases and
wider confidence intervals but also in decreased odds ratios for African
Americans and, to a lesser degree, Mexican Americans. This result may be related
to higher age-related mean FEV1/FVC values observed for the two race/ethnic
groups in the NHANES III study (21).

An increased risk of COPD has been reported for many of the associations
observed in the present study. Several general population-based studies reported
associations with specific occupational exposures. A study conducted in Tucson,
Arizona, found an association between airflow obstruction and self-reported
exposure to silica, fiberglass, sawdust, Freon (E. I. du Pont de Nemours & Co.,
Inc., Wilmington, Delaware), automobile exhaust, solvents, and construction work
(5). The US Six-City study found associations of chronic respiratory symptoms
and COPD with working with dusts, fumes, and gases (6).

In addition, studies in Norway found significant associations between airflow
obstruction and occupational exposure to quartz (11–13), ammonia, nitrous gas,
sulfur dioxide gas, metal fumes, and anhydrides (13). A study of New Zealand
subjects aged 20–44 years found associations between airflow obstruction
(FEV1/FVC <75 percent) and working as cleaners, bakers, spray painters,
laboratory technicians, and plastics and rubber workers and in construction and
mining. In addition, shortness of breath was reported more frequently by
hairdressers and chemical processors. Chronic bronchitis was reported more often
in food processors, chemical processors, and spray painters and in construction
and mining. In a large international study of subjects aged 20–44 years,
self-reported occupational exposure to vapors, gas, dust, or fumes was
associated with chronic bronchitis in agricultural, textile, paper, wood,
chemical, and food processing workers (15). In the Netherlands, the Zutphen
study found an increased risk of nonspecific lung disease for textile workers
and tailors (relative risk (RR) = 2.4), construction and cement workers (RR =
2.3), transportation workers (RR = 2.1), furnace workers (RR = 2.1), wood and
paper workers (RR = 1.7), and farmers (RR = 1.6) (33). Industry-based studies of
COPD have found an increased risk in textile mills (34), the rubber industry
(35), mining, construction, chemical production, food products manufacturing,
and agriculture (36–39).

The US Work-Related Lung Disease Surveillance Report lists industries associated
with significantly elevated proportional mortality ratios for COPD (40). In
support of our findings, the proportional mortality ratios for taxicab services,
trucking services, automotive and miscellaneous repair services, construction,
gasoline service stations, and the military were among the highest. On the other
hand, mining and potteries, which had the highest proportional mortality ratios
listed in the Work-Related Lung Disease Surveillance Report, were not identified
by the present study primarily because of limitations described in the paragraph
that follows.

To our knowledge, previous epidemiologic studies have not reported an increased
risk of COPD for industries such as utilities, the armed forces, office building
services, sales, and health care and for occupations such as records processing
clerks as well as freight, stock, and material handlers. (The records processing
clerks category includes mail handlers.) The National Institute for Occupational
Safety and Health conducted several Health Hazard Evaluations in mail processing
and distribution plants in response to workers’ complaints of work-related upper
and lower respiratory symptoms and asthma (41). In addition, an epidemiologic
study found decrements in lung function associated with more than 10 years of
high exposure to paper dust (42).

The strengths of the present study include reliable lung function data, a large
sample size that allowed for unbiased estimation of the effect of the
confounding factors, and varied industrial and job exposures. Application of the
sampling weights resulted in odds ratios that were similar to those obtained
from unweighted analyses. The limitations of the study are mainly due to the
study design and include the following: 1) the NHANES III survey was not
designed to be representative of US employment patterns, thus potentially
obscuring the importance of some high-risk work; 2) industry and occupation
categories were not always homogenous with respect to exposure to respiratory
hazards; 3) lack of detailed industry/occupation codes undoubtedly resulted in
some misclassification of exposure; and 4) the cross-sectional study design has
limitations for the ascertainment of correct causal exposure.

In conclusion, the results of the present study show that employment in specific
industries and occupations is associated with an increased risk of developing
COPD, and they add further evidence that occupational exposures contribute
significantly to the overall burden of COPD. Part of this burden may be due to
the synergistic effect of tobacco smoking and occupational exposure (43). More
research is needed to confirm that the newly identified industries and
occupations are associated with an increased risk of COPD and to identify causal
risk factors. To maximize the impact of this research on reducing the prevalence
of COPD in the US population, etiologic research and preventive interventions
should focus on industries that have high odds ratios and a large number of
cases attributable to workplace exposure.



Correspondence to Dr. Eva Hnizdo, Division of Respiratory Disease Studies, MS
H2800, National Institute for Occupational Safety and Health, 1095 Willowdale
Road, Morgantown, WV 26505 (e-mail: Exh6@cdc.gov).



TABLE 1.

Mean (standard error) FEV1*% predicted, FVC*% predicted, and FEV1/FVC ratio for
subjects without COPD,* with COPD, and with physician-diagnosed emphysema and
chronic bronchitis, Third National Health and Nutrition Examination Survey
subjects aged 30–75 years, United States, 1988–1994

COPD group No. FEV1% predicted FVC% predicted FEV1/FVC ratio Without
COPD 9,130 98.0 (0.1) 98.9 (0.2) 79.2 (0.1) With COPD† 693 63.8 (0.5) 83.5
(0.6) 58.7 (0.4) With physician-diagnosed emphysema‡ 156 69.9 (2.0) 87.0
(1.5) 60.2 (1.3) With physician-diagnosed chronic bronchitis‡ 438 87.2
(0.9) 92.7 (0.7) 74.0 (0.6) 

COPD group No. FEV1% predicted FVC% predicted FEV1/FVC ratio Without
COPD 9,130 98.0 (0.1) 98.9 (0.2) 79.2 (0.1) With COPD† 693 63.8 (0.5) 83.5
(0.6) 58.7 (0.4) With physician-diagnosed emphysema‡ 156 69.9 (2.0) 87.0
(1.5) 60.2 (1.3) With physician-diagnosed chronic bronchitis‡ 438 87.2
(0.9) 92.7 (0.7) 74.0 (0.6) 

* FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; COPD,
chronic obstructive pulmonary disease.

† COPD defined epidemiologically as FEV1/FVC <70% and FEV1 <80% predicted.

‡ Subjects are not mutually exclusive from those in the other groups.

Open in new tab
TABLE 1.

Mean (standard error) FEV1*% predicted, FVC*% predicted, and FEV1/FVC ratio for
subjects without COPD,* with COPD, and with physician-diagnosed emphysema and
chronic bronchitis, Third National Health and Nutrition Examination Survey
subjects aged 30–75 years, United States, 1988–1994

COPD group No. FEV1% predicted FVC% predicted FEV1/FVC ratio Without
COPD 9,130 98.0 (0.1) 98.9 (0.2) 79.2 (0.1) With COPD† 693 63.8 (0.5) 83.5
(0.6) 58.7 (0.4) With physician-diagnosed emphysema‡ 156 69.9 (2.0) 87.0
(1.5) 60.2 (1.3) With physician-diagnosed chronic bronchitis‡ 438 87.2
(0.9) 92.7 (0.7) 74.0 (0.6) 

COPD group No. FEV1% predicted FVC% predicted FEV1/FVC ratio Without
COPD 9,130 98.0 (0.1) 98.9 (0.2) 79.2 (0.1) With COPD† 693 63.8 (0.5) 83.5
(0.6) 58.7 (0.4) With physician-diagnosed emphysema‡ 156 69.9 (2.0) 87.0
(1.5) 60.2 (1.3) With physician-diagnosed chronic bronchitis‡ 438 87.2
(0.9) 92.7 (0.7) 74.0 (0.6) 

* FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; COPD,
chronic obstructive pulmonary disease.

† COPD defined epidemiologically as FEV1/FVC <70% and FEV1 <80% predicted.

‡ Subjects are not mutually exclusive from those in the other groups.

Open in new tab
TABLE 2.

Distribution of all study subjects and never smokers by nonoccupational risk
factors for COPD* and population prevalence of COPD, Third National Health and
Nutrition Examination Survey subjects aged 30–75 years, United States, 1988–1994

Risk factor All subjects  Never smokers No. P* (%) (SE*)  No. P (%)
(SE) Total 9,823  7.0 (0.4)  4,369 2.5 (0.3)       Race      Caucasian 4,086 7.5
(0.5)  1,658 2.5 (0.5) African American 2,774 4.9 (0.5)  1,174 1.6 (0.4) Mexican
American 2,568 2.7 (0.4)  1,312 1.7 (0.3)  Other 395 5.9 (1.5)  225 3.8
(1.3) Age category (years)†      30–39 4,324 1.9 (0.4)  2,098 1.0
(0.4) 40–49 1,717 6.7 (1.0)  713 1.4 (0.7) 50–59 1,820 13.3 (1.2)  725 5.0
(1.1) 60–75 1,962 17.5 (1.5)  833 6.9 (1.2) Sex      Male 4,657 7.8
(0.6)  1,398 2.3 (0.6) Female 5,166 6.1 (0.4)  2,971 2.5 (0.5) Smoking
status      Never smoker 4,369 2.5 (0.3)  4,369 2.5 (0.3) Former
smoker 2,735 7.9 (0.7)    Current smoker 2,719 12.8 (0.7)    No. of pack-years
(mean (standard error))‡  28.7 (0.4)    Body mass index
(kg/m2)      <38 9,445 6.9 (0.4)  4,158 2.3 (0.3) ≥38 378 10.1 (3.3)  211 7.3
(3.0) College education      Yes 2,973 4.1 (0.4)  1,453 2.2 (0.5) No 6,850 9.2
(0.4)  2,916 2.7 (0.4) Poverty index§      ≥5 1,075 4.7 (0.5)  495 2.3
(5.5) 2–4.99 3,833 6.8 (0.6)  1,713 2.1 (0.4) 1–1.99 2,310 9.1 (0.9)  993 3.1
(0.7) <0.99 2,605 8.1 (0.7)  1,168 3.1 (1.0) 

Risk factor All subjects  Never smokers No. P* (%) (SE*)  No. P (%)
(SE) Total 9,823  7.0 (0.4)  4,369 2.5 (0.3)       Race      Caucasian 4,086 7.5
(0.5)  1,658 2.5 (0.5) African American 2,774 4.9 (0.5)  1,174 1.6 (0.4) Mexican
American 2,568 2.7 (0.4)  1,312 1.7 (0.3)  Other 395 5.9 (1.5)  225 3.8
(1.3) Age category (years)†      30–39 4,324 1.9 (0.4)  2,098 1.0
(0.4) 40–49 1,717 6.7 (1.0)  713 1.4 (0.7) 50–59 1,820 13.3 (1.2)  725 5.0
(1.1) 60–75 1,962 17.5 (1.5)  833 6.9 (1.2) Sex      Male 4,657 7.8
(0.6)  1,398 2.3 (0.6) Female 5,166 6.1 (0.4)  2,971 2.5 (0.5) Smoking
status      Never smoker 4,369 2.5 (0.3)  4,369 2.5 (0.3) Former
smoker 2,735 7.9 (0.7)    Current smoker 2,719 12.8 (0.7)    No. of pack-years
(mean (standard error))‡  28.7 (0.4)    Body mass index
(kg/m2)      <38 9,445 6.9 (0.4)  4,158 2.3 (0.3) ≥38 378 10.1 (3.3)  211 7.3
(3.0) College education      Yes 2,973 4.1 (0.4)  1,453 2.2 (0.5) No 6,850 9.2
(0.4)  2,916 2.7 (0.4) Poverty index§      ≥5 1,075 4.7 (0.5)  495 2.3
(5.5) 2–4.99 3,833 6.8 (0.6)  1,713 2.1 (0.4) 1–1.99 2,310 9.1 (0.9)  993 3.1
(0.7) <0.99 2,605 8.1 (0.7)  1,168 3.1 (1.0) 

* COPD, chronic obstructive pulmonary disease; P, prevalence; SE, standard
error.

† 5-year age categories were fitted in the logistic model.

‡ Mean and standard error values were averaged over former smokers and current
smokers only.

§ Poverty increases with decreasing poverty index value.

Open in new tab
TABLE 2.

Distribution of all study subjects and never smokers by nonoccupational risk
factors for COPD* and population prevalence of COPD, Third National Health and
Nutrition Examination Survey subjects aged 30–75 years, United States, 1988–1994

Risk factor All subjects  Never smokers No. P* (%) (SE*)  No. P (%)
(SE) Total 9,823  7.0 (0.4)  4,369 2.5 (0.3)       Race      Caucasian 4,086 7.5
(0.5)  1,658 2.5 (0.5) African American 2,774 4.9 (0.5)  1,174 1.6 (0.4) Mexican
American 2,568 2.7 (0.4)  1,312 1.7 (0.3)  Other 395 5.9 (1.5)  225 3.8
(1.3) Age category (years)†      30–39 4,324 1.9 (0.4)  2,098 1.0
(0.4) 40–49 1,717 6.7 (1.0)  713 1.4 (0.7) 50–59 1,820 13.3 (1.2)  725 5.0
(1.1) 60–75 1,962 17.5 (1.5)  833 6.9 (1.2) Sex      Male 4,657 7.8
(0.6)  1,398 2.3 (0.6) Female 5,166 6.1 (0.4)  2,971 2.5 (0.5) Smoking
status      Never smoker 4,369 2.5 (0.3)  4,369 2.5 (0.3) Former
smoker 2,735 7.9 (0.7)    Current smoker 2,719 12.8 (0.7)    No. of pack-years
(mean (standard error))‡  28.7 (0.4)    Body mass index
(kg/m2)      <38 9,445 6.9 (0.4)  4,158 2.3 (0.3) ≥38 378 10.1 (3.3)  211 7.3
(3.0) College education      Yes 2,973 4.1 (0.4)  1,453 2.2 (0.5) No 6,850 9.2
(0.4)  2,916 2.7 (0.4) Poverty index§      ≥5 1,075 4.7 (0.5)  495 2.3
(5.5) 2–4.99 3,833 6.8 (0.6)  1,713 2.1 (0.4) 1–1.99 2,310 9.1 (0.9)  993 3.1
(0.7) <0.99 2,605 8.1 (0.7)  1,168 3.1 (1.0) 

Risk factor All subjects  Never smokers No. P* (%) (SE*)  No. P (%)
(SE) Total 9,823  7.0 (0.4)  4,369 2.5 (0.3)       Race      Caucasian 4,086 7.5
(0.5)  1,658 2.5 (0.5) African American 2,774 4.9 (0.5)  1,174 1.6 (0.4) Mexican
American 2,568 2.7 (0.4)  1,312 1.7 (0.3)  Other 395 5.9 (1.5)  225 3.8
(1.3) Age category (years)†      30–39 4,324 1.9 (0.4)  2,098 1.0
(0.4) 40–49 1,717 6.7 (1.0)  713 1.4 (0.7) 50–59 1,820 13.3 (1.2)  725 5.0
(1.1) 60–75 1,962 17.5 (1.5)  833 6.9 (1.2) Sex      Male 4,657 7.8
(0.6)  1,398 2.3 (0.6) Female 5,166 6.1 (0.4)  2,971 2.5 (0.5) Smoking
status      Never smoker 4,369 2.5 (0.3)  4,369 2.5 (0.3) Former
smoker 2,735 7.9 (0.7)    Current smoker 2,719 12.8 (0.7)    No. of pack-years
(mean (standard error))‡  28.7 (0.4)    Body mass index
(kg/m2)      <38 9,445 6.9 (0.4)  4,158 2.3 (0.3) ≥38 378 10.1 (3.3)  211 7.3
(3.0) College education      Yes 2,973 4.1 (0.4)  1,453 2.2 (0.5) No 6,850 9.2
(0.4)  2,916 2.7 (0.4) Poverty index§      ≥5 1,075 4.7 (0.5)  495 2.3
(5.5) 2–4.99 3,833 6.8 (0.6)  1,713 2.1 (0.4) 1–1.99 2,310 9.1 (0.9)  993 3.1
(0.7) <0.99 2,605 8.1 (0.7)  1,168 3.1 (1.0) 

* COPD, chronic obstructive pulmonary disease; P, prevalence; SE, standard
error.

† 5-year age categories were fitted in the logistic model.

‡ Mean and standard error values were averaged over former smokers and current
smokers only.

§ Poverty increases with decreasing poverty index value.

Open in new tab
TABLE 3.

COPD* by industry, Third National Health and Nutrition Examination Survey
subjects aged 30–75 years, United States, 1988–1994

Industry All subjects (n = 9,823)†  Never smokers (n = 4,369)‡ N* P* (%)
(SE*) n* COPD§ OR*,¶ 95% CI* AC*  N P (%) (SE) n COPD OR¶ 95% CI AC Rubber,
plastics, leather manufacturing 9.0 14.8 (3.9) 71 9 2.5 1.4, 4.4 0.8  3.1 4.8
(2.4) 39 2 2.5 1.0, 6.4 0.1 Utilities 12.0 16.7 (6.0) 94 12 2.4 0.7,
7.7 1.2  2.2 24.6 (16) 23 2 27.7 3.6, 214 0.5 Office building services (males
) 5.4 13.6 (6.6)  84 12 2.4 0.7, 7.8 0.4  1.0 0.0 (0.0) 18 0    Textile mill
products manufacturing 15.4 15.3 (4.6) 163 20 2.2 1.1, 4.2 1.3  6.3 5.2
(4.1) 71 5 3.1 0.4, 28 0.2 Armed forces 14.0 13.3 (3.5) 119 16 2.2 1.2,
3.9 1.0  4.5 11.6 (7.2) 40 2 4.4 0.9, 20 0.4 Food products
manufacturing 21.0 13.9 (3.0) 267 27 2.1 1.1, 4.1 1.5  6.9 3.8
(2.8) 119 4 2.1 0.3, 14 0.1 Repair service, gas station 29.6 12.0
(3.0) 256 22 1.5 0.8, 2.9 1.2  8.6 0.0 (0.0) 61 0    Chemicals, petroleum, coal
manufacturing 13.7 11.6 (4.1) 107 10 1.5 0.5, 4.4 0.5  6.1 5.4
(5.6) 44 1 2.6 0.2, 27 0.2 Agriculture 39.0 10.4 (1.9) 598 60 1.5 0.8,
2.7 1.4  17.8 1.8 (1.0) 246 7 0.8 0.2, 2.8  Sales 136.5 8.3
(1.2) 1,012 83 1.4 0.9, 2.2 3.2  59.9 3.2 (1.3) 441 13 1.9 0.6,
5.5 0.9 Construction 54.3 8.7 (2.0) 493 46 1.3 0.8, 2.3 1.1  12.9 4.9
(2.7) 129 6 3.5 0.9, 14 0.5 Transportation and trucking 35.9 8.9
(2.2) 325 32 1.2 0.8, 2.0 0.5  12.4 2.3 (1.9) 91 4 2.0 0.3, 15 0.1 Personal
services 40.3 6.1 (1.6) 543 41 1.1 0.6, 2.0 0.2  21.4 1.5 (0.7) 308 13 0.6 0.2,
2.3  Health care 74.4 4.4 (1.3) 653 27 1.1 0.6, 2.1 0.3  39.9 2.5
(1.2) 349 7 1.8 0.5, 5.6 0.4 Other industries# 201.5 6.1
(0.8) 2,090 124 0.8 0.6, 1.2   64.7 1.8 (0.7) 844 20 0.9 0.3, 2.5  Office
workers 401.0 4.7 (0.4) 2,653 133 1.0    197 1.8
(0.5) 1,335 20 1.0                   Total working population** 1,103 6.9
(0.4) 9,528 674   14.7  465 2.4 (0.3) 4,158 106   3.5 

Industry All subjects (n = 9,823)†  Never smokers (n = 4,369)‡ N* P* (%)
(SE*) n* COPD§ OR*,¶ 95% CI* AC*  N P (%) (SE) n COPD OR¶ 95% CI AC Rubber,
plastics, leather manufacturing 9.0 14.8 (3.9) 71 9 2.5 1.4, 4.4 0.8  3.1 4.8
(2.4) 39 2 2.5 1.0, 6.4 0.1 Utilities 12.0 16.7 (6.0) 94 12 2.4 0.7,
7.7 1.2  2.2 24.6 (16) 23 2 27.7 3.6, 214 0.5 Office building services (males
) 5.4 13.6 (6.6)  84 12 2.4 0.7, 7.8 0.4  1.0 0.0 (0.0) 18 0    Textile mill
products manufacturing 15.4 15.3 (4.6) 163 20 2.2 1.1, 4.2 1.3  6.3 5.2
(4.1) 71 5 3.1 0.4, 28 0.2 Armed forces 14.0 13.3 (3.5) 119 16 2.2 1.2,
3.9 1.0  4.5 11.6 (7.2) 40 2 4.4 0.9, 20 0.4 Food products
manufacturing 21.0 13.9 (3.0) 267 27 2.1 1.1, 4.1 1.5  6.9 3.8
(2.8) 119 4 2.1 0.3, 14 0.1 Repair service, gas station 29.6 12.0
(3.0) 256 22 1.5 0.8, 2.9 1.2  8.6 0.0 (0.0) 61 0    Chemicals, petroleum, coal
manufacturing 13.7 11.6 (4.1) 107 10 1.5 0.5, 4.4 0.5  6.1 5.4
(5.6) 44 1 2.6 0.2, 27 0.2 Agriculture 39.0 10.4 (1.9) 598 60 1.5 0.8,
2.7 1.4  17.8 1.8 (1.0) 246 7 0.8 0.2, 2.8  Sales 136.5 8.3
(1.2) 1,012 83 1.4 0.9, 2.2 3.2  59.9 3.2 (1.3) 441 13 1.9 0.6,
5.5 0.9 Construction 54.3 8.7 (2.0) 493 46 1.3 0.8, 2.3 1.1  12.9 4.9
(2.7) 129 6 3.5 0.9, 14 0.5 Transportation and trucking 35.9 8.9
(2.2) 325 32 1.2 0.8, 2.0 0.5  12.4 2.3 (1.9) 91 4 2.0 0.3, 15 0.1 Personal
services 40.3 6.1 (1.6) 543 41 1.1 0.6, 2.0 0.2  21.4 1.5 (0.7) 308 13 0.6 0.2,
2.3  Health care 74.4 4.4 (1.3) 653 27 1.1 0.6, 2.1 0.3  39.9 2.5
(1.2) 349 7 1.8 0.5, 5.6 0.4 Other industries# 201.5 6.1
(0.8) 2,090 124 0.8 0.6, 1.2   64.7 1.8 (0.7) 844 20 0.9 0.3, 2.5  Office
workers 401.0 4.7 (0.4) 2,653 133 1.0    197 1.8
(0.5) 1,335 20 1.0                   Total working population** 1,103 6.9
(0.4) 9,528 674   14.7  465 2.4 (0.3) 4,158 106   3.5 

* COPD, chronic obstructive pulmonary disease; N, estimated number of US workers
in 100,000; P, population prevalence; SE, standard error; n, sample size; OR,
odds ratio; CI, confidence interval; AC, number of attributable cases in
100,000.

† For this model, the model goodness-of-fit Wald F(df = 38) = 297, p < 0.0001;
for industry, Wald F(df = 16) = 2.7, p < 0.004.

‡ For this model, the model goodness-of-fit Wald F(df = 28) = 98.3, p < 0.0001;
for industry, Wald F(df = 16) = 2.5, p = 0.009.

§ Number of cases with COPD.

¶ Adjusted for age, sex, race/ethnic group, body mass index, smoking status,
pack-years of cigarette smoking, education, and socioeconomic status.

# Includes industries for which the adjusted odds ratios were not increased;
refer to the text.

** Excluded were 295 subjects who never worked, of whom 211 were never smokers.

Open in new tab
TABLE 3.

COPD* by industry, Third National Health and Nutrition Examination Survey
subjects aged 30–75 years, United States, 1988–1994

Industry All subjects (n = 9,823)†  Never smokers (n = 4,369)‡ N* P* (%)
(SE*) n* COPD§ OR*,¶ 95% CI* AC*  N P (%) (SE) n COPD OR¶ 95% CI AC Rubber,
plastics, leather manufacturing 9.0 14.8 (3.9) 71 9 2.5 1.4, 4.4 0.8  3.1 4.8
(2.4) 39 2 2.5 1.0, 6.4 0.1 Utilities 12.0 16.7 (6.0) 94 12 2.4 0.7,
7.7 1.2  2.2 24.6 (16) 23 2 27.7 3.6, 214 0.5 Office building services (males
) 5.4 13.6 (6.6)  84 12 2.4 0.7, 7.8 0.4  1.0 0.0 (0.0) 18 0    Textile mill
products manufacturing 15.4 15.3 (4.6) 163 20 2.2 1.1, 4.2 1.3  6.3 5.2
(4.1) 71 5 3.1 0.4, 28 0.2 Armed forces 14.0 13.3 (3.5) 119 16 2.2 1.2,
3.9 1.0  4.5 11.6 (7.2) 40 2 4.4 0.9, 20 0.4 Food products
manufacturing 21.0 13.9 (3.0) 267 27 2.1 1.1, 4.1 1.5  6.9 3.8
(2.8) 119 4 2.1 0.3, 14 0.1 Repair service, gas station 29.6 12.0
(3.0) 256 22 1.5 0.8, 2.9 1.2  8.6 0.0 (0.0) 61 0    Chemicals, petroleum, coal
manufacturing 13.7 11.6 (4.1) 107 10 1.5 0.5, 4.4 0.5  6.1 5.4
(5.6) 44 1 2.6 0.2, 27 0.2 Agriculture 39.0 10.4 (1.9) 598 60 1.5 0.8,
2.7 1.4  17.8 1.8 (1.0) 246 7 0.8 0.2, 2.8  Sales 136.5 8.3
(1.2) 1,012 83 1.4 0.9, 2.2 3.2  59.9 3.2 (1.3) 441 13 1.9 0.6,
5.5 0.9 Construction 54.3 8.7 (2.0) 493 46 1.3 0.8, 2.3 1.1  12.9 4.9
(2.7) 129 6 3.5 0.9, 14 0.5 Transportation and trucking 35.9 8.9
(2.2) 325 32 1.2 0.8, 2.0 0.5  12.4 2.3 (1.9) 91 4 2.0 0.3, 15 0.1 Personal
services 40.3 6.1 (1.6) 543 41 1.1 0.6, 2.0 0.2  21.4 1.5 (0.7) 308 13 0.6 0.2,
2.3  Health care 74.4 4.4 (1.3) 653 27 1.1 0.6, 2.1 0.3  39.9 2.5
(1.2) 349 7 1.8 0.5, 5.6 0.4 Other industries# 201.5 6.1
(0.8) 2,090 124 0.8 0.6, 1.2   64.7 1.8 (0.7) 844 20 0.9 0.3, 2.5  Office
workers 401.0 4.7 (0.4) 2,653 133 1.0    197 1.8
(0.5) 1,335 20 1.0                   Total working population** 1,103 6.9
(0.4) 9,528 674   14.7  465 2.4 (0.3) 4,158 106   3.5 

Industry All subjects (n = 9,823)†  Never smokers (n = 4,369)‡ N* P* (%)
(SE*) n* COPD§ OR*,¶ 95% CI* AC*  N P (%) (SE) n COPD OR¶ 95% CI AC Rubber,
plastics, leather manufacturing 9.0 14.8 (3.9) 71 9 2.5 1.4, 4.4 0.8  3.1 4.8
(2.4) 39 2 2.5 1.0, 6.4 0.1 Utilities 12.0 16.7 (6.0) 94 12 2.4 0.7,
7.7 1.2  2.2 24.6 (16) 23 2 27.7 3.6, 214 0.5 Office building services (males
) 5.4 13.6 (6.6)  84 12 2.4 0.7, 7.8 0.4  1.0 0.0 (0.0) 18 0    Textile mill
products manufacturing 15.4 15.3 (4.6) 163 20 2.2 1.1, 4.2 1.3  6.3 5.2
(4.1) 71 5 3.1 0.4, 28 0.2 Armed forces 14.0 13.3 (3.5) 119 16 2.2 1.2,
3.9 1.0  4.5 11.6 (7.2) 40 2 4.4 0.9, 20 0.4 Food products
manufacturing 21.0 13.9 (3.0) 267 27 2.1 1.1, 4.1 1.5  6.9 3.8
(2.8) 119 4 2.1 0.3, 14 0.1 Repair service, gas station 29.6 12.0
(3.0) 256 22 1.5 0.8, 2.9 1.2  8.6 0.0 (0.0) 61 0    Chemicals, petroleum, coal
manufacturing 13.7 11.6 (4.1) 107 10 1.5 0.5, 4.4 0.5  6.1 5.4
(5.6) 44 1 2.6 0.2, 27 0.2 Agriculture 39.0 10.4 (1.9) 598 60 1.5 0.8,
2.7 1.4  17.8 1.8 (1.0) 246 7 0.8 0.2, 2.8  Sales 136.5 8.3
(1.2) 1,012 83 1.4 0.9, 2.2 3.2  59.9 3.2 (1.3) 441 13 1.9 0.6,
5.5 0.9 Construction 54.3 8.7 (2.0) 493 46 1.3 0.8, 2.3 1.1  12.9 4.9
(2.7) 129 6 3.5 0.9, 14 0.5 Transportation and trucking 35.9 8.9
(2.2) 325 32 1.2 0.8, 2.0 0.5  12.4 2.3 (1.9) 91 4 2.0 0.3, 15 0.1 Personal
services 40.3 6.1 (1.6) 543 41 1.1 0.6, 2.0 0.2  21.4 1.5 (0.7) 308 13 0.6 0.2,
2.3  Health care 74.4 4.4 (1.3) 653 27 1.1 0.6, 2.1 0.3  39.9 2.5
(1.2) 349 7 1.8 0.5, 5.6 0.4 Other industries# 201.5 6.1
(0.8) 2,090 124 0.8 0.6, 1.2   64.7 1.8 (0.7) 844 20 0.9 0.3, 2.5  Office
workers 401.0 4.7 (0.4) 2,653 133 1.0    197 1.8
(0.5) 1,335 20 1.0                   Total working population** 1,103 6.9
(0.4) 9,528 674   14.7  465 2.4 (0.3) 4,158 106   3.5 

* COPD, chronic obstructive pulmonary disease; N, estimated number of US workers
in 100,000; P, population prevalence; SE, standard error; n, sample size; OR,
odds ratio; CI, confidence interval; AC, number of attributable cases in
100,000.

† For this model, the model goodness-of-fit Wald F(df = 38) = 297, p < 0.0001;
for industry, Wald F(df = 16) = 2.7, p < 0.004.

‡ For this model, the model goodness-of-fit Wald F(df = 28) = 98.3, p < 0.0001;
for industry, Wald F(df = 16) = 2.5, p = 0.009.

§ Number of cases with COPD.

¶ Adjusted for age, sex, race/ethnic group, body mass index, smoking status,
pack-years of cigarette smoking, education, and socioeconomic status.

# Includes industries for which the adjusted odds ratios were not increased;
refer to the text.

** Excluded were 295 subjects who never worked, of whom 211 were never smokers.

Open in new tab
TABLE 4.

COPD* by occupation, Third National Health and Nutrition Examination Survey
subjects aged 30–75 years, United States, 1988–1994

Occupation All subjects†  Never smokers ‡ N* P* (%) (SE*) n* COPD§ OR*,¶ 95% CI
 AC*  N P (%) (SE) n COPD OR¶ 95% CI AC§ Freight, stock, material handlers
 8.3 8.4 (2.0) 87 8 2.2 1.3, 3.7 0.4  4.8 0.8 (0.7) 36 2 0.8 0.2, 4.0  Armed
forces 14.0 13.4 (3.5) 117 16 2.0 1.1, 3.6 0.9  4.4 11.8 (7.3) 39 2 4.1 0.9,
19.4 0.4 Vehicle mechanics 21.1 12.8 (3.7) 149 15 2.0 0.9, 4.1 1.4  6.4 0.6
(0.0) 40 1 0.4 0.0, 3.4  Records processing, distribution clerks 43.9 10.4
(2.6) 370 31 1.8 0.8, 3.6 2.0  20.3 5.5 (2.1) 171 8 2.9 1.1, 7.6 0.7 Sales:
retail, personal services 82.2 9.1 (1.7) 564 48 1.5 0.8, 2.6 2.5  36.3 3.8
(2.0) 263 8 2.1 0.5, 8.6 0.7 Transportation, material moving 13.8 13.2
(4.5) 146 16 1.4 0.6, 3.0 0.5  3.6 1.1 (1.0) 36 1 0.5 0.1, 5.2  Other machine
operators 49.1 9.8 (2.0) 562 44 1.3 0.7, 2.5 1.1  13.8 6.5 (3.2) 216 9 3.8 0.9,
16.1 0.7 Agriculture 38.9 10.2 (2.1) 592 60 1.3 0.7, 2.5 0.9  16.7 2.3
(1.1) 241 9 1.0 0.3, 3.1  Construction trades, laborers 50.1 7.5
(2.0) 456 41 1.2 0.6, 2.5 0.6  12.0 4.8 (2.6) 119 6 3.4 1.1, 10.5 0.4 Motor
vehicle operators 30.9 11.3 (2.3) 348 34 1.2 0.7, 2.1 0.6  7.1 2.6
(2.5) 83 2 1.8 0.2, 14.3 0.1 Textile, apparel machine operators 25.9 10.4
(2.5) 327 25 1.2 0.7, 1.9 0.5  11.1 1.9 (0.9) 171 6 0.7 0.3,
2.1  Waitresses 13.5 9.3 (3.4) 105 11 1.1 0.5, 2.5 0.1  3.2 4.8
(4.4) 35 2 2.0 0.3, 15.2 0.1 Other occupations 365.8 5.6
(0.6) 3,395 204 0.9 0.7, 1.2   153.2 4.5 (0.5) 1,531 31 0.8 0.3, 2.0  Office
workers 342.5 4.9 (0.4) 2,277 118 1.0    169.9 2.0
(0.5) 1,159 19 1.0                   Total working population** 1,100.0 7.0
(0.4) 9,495 671   11.5  462.8 2.5 (0.4) 4,140 106   3.1 

Occupation All subjects†  Never smokers ‡ N* P* (%) (SE*) n* COPD§ OR*,¶ 95% CI
 AC*  N P (%) (SE) n COPD OR¶ 95% CI AC§ Freight, stock, material handlers
 8.3 8.4 (2.0) 87 8 2.2 1.3, 3.7 0.4  4.8 0.8 (0.7) 36 2 0.8 0.2, 4.0  Armed
forces 14.0 13.4 (3.5) 117 16 2.0 1.1, 3.6 0.9  4.4 11.8 (7.3) 39 2 4.1 0.9,
19.4 0.4 Vehicle mechanics 21.1 12.8 (3.7) 149 15 2.0 0.9, 4.1 1.4  6.4 0.6
(0.0) 40 1 0.4 0.0, 3.4  Records processing, distribution clerks 43.9 10.4
(2.6) 370 31 1.8 0.8, 3.6 2.0  20.3 5.5 (2.1) 171 8 2.9 1.1, 7.6 0.7 Sales:
retail, personal services 82.2 9.1 (1.7) 564 48 1.5 0.8, 2.6 2.5  36.3 3.8
(2.0) 263 8 2.1 0.5, 8.6 0.7 Transportation, material moving 13.8 13.2
(4.5) 146 16 1.4 0.6, 3.0 0.5  3.6 1.1 (1.0) 36 1 0.5 0.1, 5.2  Other machine
operators 49.1 9.8 (2.0) 562 44 1.3 0.7, 2.5 1.1  13.8 6.5 (3.2) 216 9 3.8 0.9,
16.1 0.7 Agriculture 38.9 10.2 (2.1) 592 60 1.3 0.7, 2.5 0.9  16.7 2.3
(1.1) 241 9 1.0 0.3, 3.1  Construction trades, laborers 50.1 7.5
(2.0) 456 41 1.2 0.6, 2.5 0.6  12.0 4.8 (2.6) 119 6 3.4 1.1, 10.5 0.4 Motor
vehicle operators 30.9 11.3 (2.3) 348 34 1.2 0.7, 2.1 0.6  7.1 2.6
(2.5) 83 2 1.8 0.2, 14.3 0.1 Textile, apparel machine operators 25.9 10.4
(2.5) 327 25 1.2 0.7, 1.9 0.5  11.1 1.9 (0.9) 171 6 0.7 0.3,
2.1  Waitresses 13.5 9.3 (3.4) 105 11 1.1 0.5, 2.5 0.1  3.2 4.8
(4.4) 35 2 2.0 0.3, 15.2 0.1 Other occupations 365.8 5.6
(0.6) 3,395 204 0.9 0.7, 1.2   153.2 4.5 (0.5) 1,531 31 0.8 0.3, 2.0  Office
workers 342.5 4.9 (0.4) 2,277 118 1.0    169.9 2.0
(0.5) 1,159 19 1.0                   Total working population** 1,100.0 7.0
(0.4) 9,495 671   11.5  462.8 2.5 (0.4) 4,140 106   3.1 

* COPD, chronic obstructive pulmonary disease; N, estimated number of US workers
in 100,000; P, population prevalence; SE, standard error; n, sample size; OR,
odds ratio; CI, confidence interval; AC, number of attributable cases in
100,000.

† For this model, the model goodness-of-fit Wald F(df =32) = 337, p < 0.0001;
for occupation, Wald F(df=14) = 2.3, p < 0.02.

‡ For this model, the overall model goodness-of-fit Wald F(df=28) = 105, p <
0.0001; for occupation, Wald F(df=14) = 2.1, p = 0.03.

§ Number of cases with COPD.

¶ Adjusted for age, sex, race/ethnic group, body mass index, smoking status,
pack-years of cigarette smoking, education, and socioeconomic status.

Includes industries for which the adjusted odds ratios were <1; refer to the
text.

** Excluded were 33 subjects whose occupations were unknown and 295 subjects who
never worked, of whom 211 were never smokers.

Open in new tab
TABLE 4.

COPD* by occupation, Third National Health and Nutrition Examination Survey
subjects aged 30–75 years, United States, 1988–1994

Occupation All subjects†  Never smokers ‡ N* P* (%) (SE*) n* COPD§ OR*,¶ 95% CI
 AC*  N P (%) (SE) n COPD OR¶ 95% CI AC§ Freight, stock, material handlers
 8.3 8.4 (2.0) 87 8 2.2 1.3, 3.7 0.4  4.8 0.8 (0.7) 36 2 0.8 0.2, 4.0  Armed
forces 14.0 13.4 (3.5) 117 16 2.0 1.1, 3.6 0.9  4.4 11.8 (7.3) 39 2 4.1 0.9,
19.4 0.4 Vehicle mechanics 21.1 12.8 (3.7) 149 15 2.0 0.9, 4.1 1.4  6.4 0.6
(0.0) 40 1 0.4 0.0, 3.4  Records processing, distribution clerks 43.9 10.4
(2.6) 370 31 1.8 0.8, 3.6 2.0  20.3 5.5 (2.1) 171 8 2.9 1.1, 7.6 0.7 Sales:
retail, personal services 82.2 9.1 (1.7) 564 48 1.5 0.8, 2.6 2.5  36.3 3.8
(2.0) 263 8 2.1 0.5, 8.6 0.7 Transportation, material moving 13.8 13.2
(4.5) 146 16 1.4 0.6, 3.0 0.5  3.6 1.1 (1.0) 36 1 0.5 0.1, 5.2  Other machine
operators 49.1 9.8 (2.0) 562 44 1.3 0.7, 2.5 1.1  13.8 6.5 (3.2) 216 9 3.8 0.9,
16.1 0.7 Agriculture 38.9 10.2 (2.1) 592 60 1.3 0.7, 2.5 0.9  16.7 2.3
(1.1) 241 9 1.0 0.3, 3.1  Construction trades, laborers 50.1 7.5
(2.0) 456 41 1.2 0.6, 2.5 0.6  12.0 4.8 (2.6) 119 6 3.4 1.1, 10.5 0.4 Motor
vehicle operators 30.9 11.3 (2.3) 348 34 1.2 0.7, 2.1 0.6  7.1 2.6
(2.5) 83 2 1.8 0.2, 14.3 0.1 Textile, apparel machine operators 25.9 10.4
(2.5) 327 25 1.2 0.7, 1.9 0.5  11.1 1.9 (0.9) 171 6 0.7 0.3,
2.1  Waitresses 13.5 9.3 (3.4) 105 11 1.1 0.5, 2.5 0.1  3.2 4.8
(4.4) 35 2 2.0 0.3, 15.2 0.1 Other occupations 365.8 5.6
(0.6) 3,395 204 0.9 0.7, 1.2   153.2 4.5 (0.5) 1,531 31 0.8 0.3, 2.0  Office
workers 342.5 4.9 (0.4) 2,277 118 1.0    169.9 2.0
(0.5) 1,159 19 1.0                   Total working population** 1,100.0 7.0
(0.4) 9,495 671   11.5  462.8 2.5 (0.4) 4,140 106   3.1 

Occupation All subjects†  Never smokers ‡ N* P* (%) (SE*) n* COPD§ OR*,¶ 95% CI
 AC*  N P (%) (SE) n COPD OR¶ 95% CI AC§ Freight, stock, material handlers
 8.3 8.4 (2.0) 87 8 2.2 1.3, 3.7 0.4  4.8 0.8 (0.7) 36 2 0.8 0.2, 4.0  Armed
forces 14.0 13.4 (3.5) 117 16 2.0 1.1, 3.6 0.9  4.4 11.8 (7.3) 39 2 4.1 0.9,
19.4 0.4 Vehicle mechanics 21.1 12.8 (3.7) 149 15 2.0 0.9, 4.1 1.4  6.4 0.6
(0.0) 40 1 0.4 0.0, 3.4  Records processing, distribution clerks 43.9 10.4
(2.6) 370 31 1.8 0.8, 3.6 2.0  20.3 5.5 (2.1) 171 8 2.9 1.1, 7.6 0.7 Sales:
retail, personal services 82.2 9.1 (1.7) 564 48 1.5 0.8, 2.6 2.5  36.3 3.8
(2.0) 263 8 2.1 0.5, 8.6 0.7 Transportation, material moving 13.8 13.2
(4.5) 146 16 1.4 0.6, 3.0 0.5  3.6 1.1 (1.0) 36 1 0.5 0.1, 5.2  Other machine
operators 49.1 9.8 (2.0) 562 44 1.3 0.7, 2.5 1.1  13.8 6.5 (3.2) 216 9 3.8 0.9,
16.1 0.7 Agriculture 38.9 10.2 (2.1) 592 60 1.3 0.7, 2.5 0.9  16.7 2.3
(1.1) 241 9 1.0 0.3, 3.1  Construction trades, laborers 50.1 7.5
(2.0) 456 41 1.2 0.6, 2.5 0.6  12.0 4.8 (2.6) 119 6 3.4 1.1, 10.5 0.4 Motor
vehicle operators 30.9 11.3 (2.3) 348 34 1.2 0.7, 2.1 0.6  7.1 2.6
(2.5) 83 2 1.8 0.2, 14.3 0.1 Textile, apparel machine operators 25.9 10.4
(2.5) 327 25 1.2 0.7, 1.9 0.5  11.1 1.9 (0.9) 171 6 0.7 0.3,
2.1  Waitresses 13.5 9.3 (3.4) 105 11 1.1 0.5, 2.5 0.1  3.2 4.8
(4.4) 35 2 2.0 0.3, 15.2 0.1 Other occupations 365.8 5.6
(0.6) 3,395 204 0.9 0.7, 1.2   153.2 4.5 (0.5) 1,531 31 0.8 0.3, 2.0  Office
workers 342.5 4.9 (0.4) 2,277 118 1.0    169.9 2.0
(0.5) 1,159 19 1.0                   Total working population** 1,100.0 7.0
(0.4) 9,495 671   11.5  462.8 2.5 (0.4) 4,140 106   3.1 

* COPD, chronic obstructive pulmonary disease; N, estimated number of US workers
in 100,000; P, population prevalence; SE, standard error; n, sample size; OR,
odds ratio; CI, confidence interval; AC, number of attributable cases in
100,000.

† For this model, the model goodness-of-fit Wald F(df =32) = 337, p < 0.0001;
for occupation, Wald F(df=14) = 2.3, p < 0.02.

‡ For this model, the overall model goodness-of-fit Wald F(df=28) = 105, p <
0.0001; for occupation, Wald F(df=14) = 2.1, p = 0.03.

§ Number of cases with COPD.

¶ Adjusted for age, sex, race/ethnic group, body mass index, smoking status,
pack-years of cigarette smoking, education, and socioeconomic status.

Includes industries for which the adjusted odds ratios were <1; refer to the
text.

** Excluded were 33 subjects whose occupations were unknown and 295 subjects who
never worked, of whom 211 were never smokers.

Open in new tab


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