Meta-Analysis of Incidence and Mortality of Firefighter Cancer: An Update on Emerging Science.

BACKGROUND: Firefighters are faced with a broad range of toxic exposures during their work, including known and suspected carcinogens. The current study is an update to the previously published meta-analysis of cancer risk among firefighters by Soteriades and colleagues, and focuses on studies published from 2008 to 2020. METHODS: A comprehensive search of the literature was conducted, including electronic databases and bibliographies of recently published papers. Analyses include stratification of studies conducted in the United States (US) versus other countries. Cancer incidence and mortality rates were compared to the relevant general population. Random effects models were used to calculate summary risk estimates and their 95% confidence intervals. RESULTS: A total of 24 studies were included in the meta-analysis. Among the 42 cancer types covered, incidence was associated with firefighting in US samples for colon, kidney, large intestine, pleura, and prostate cancer, as well as malignant melanoma. There was an increased incidence of Hodgkin's Disease and malignant melanoma and a significantly lower risk of kidney cancer for non-US samples. Significant cancer mortality estimates for US samples included oral/buccal/mouth, other parts of the buccal cavity, pharynx, colon, esophagus, large intestine, lung, Non-Hodgkin's Lymphoma, pancreas, pleura, rectum, and soft tissue sarcoma. No cancer had a significantly higher rate of mortality among non-US samples. CONCLUSIONS: The findings underscore the global cancer burden among firefighters, and indicate that geographically stratifying studies afford a more nuanced risk perspective. Further research should investigate why US firefighters exhibit higher cancer mortality rates compared to international counterparts.

Evaluation of the Implementation of the NFFF Stress First Aid Intervention in Career Fire Departments: A Cluster Randomized Controlled Trial.

Firefighting is inherently dangerous, though recently concerns have shifted from traditional fireground injuries (burns and asphyxiation) to a focus on mental and behavioral health. Although firefighters are remarkably resilient, research suggests many suffer negative psychological consequences from repeated exposures to trauma. While the Stress First Aid (SFA) model has gained increased attention and adoption among fire departments as a model for behavioral health training, it has not been formally evaluated. This cluster randomized controlled trial used a crossover design comparing the immediate SFA group to delayed SFA control to test the impact of the SFA on firefighters' mental and behavioral health changes after 10-12 months (n = 400; Mage = 37.6, 4.8% women). A convenience sample of 79 firefighters (Mage = 41.4; 8.7% women) provided evaluations on one or more of the training modules. Participants reported satisfaction with all training components (Peer team training 97.6%, Online SFA 94.9%, Curbside Manner 88.4%, After Action Review 89.4%) and reported success in changing personnel's perception of their department's ability to respond to behavioral health issues (SFA M = 3.93, Control 3.50; t = 2.52, p = 0.042). Future work should focus on additional resources and training to augment existing efforts to help departments continue their efforts.

Comparisons of Baseline Obesity Prevalence and Its Association with Perceived Health and Physical Performance in Military Officers.

Increasing obesity rates among USA military members vary by age, pay grade, and measurement methods and threaten force fitness and readiness. Limited research has directly measured obesity among officers; those enrolled in graduate school at the Command and General Staff College (CGSC) face additional demands and increased obesity risk. This study compared obesity measurements and performance on the Army Physical Fitness test and self-rated health for a sample of mostly CGSC officers. Participants (n = 136, 75.7% male, 79.6% officers) completed body composition measures; BMI, body fat percentage (BF%), waist circumference (WC), and waist-to-height ratio (WHtR) estimated obesity rates and were compared for discordance. Army Physical Fitness Test pass/fail rates and self-reported perceived health were compared with each obesity classification. Obesity prevalence was 18.5-39.7%, differing by sex and measure. BMI, WC, and WHtR underestimated obesity compared to BF% at least 21% of the time. WHtR had the lowest discordance with BF%. Soldiers categorized as obese were significantly more likely to fail the fitness test and report lower self-rated health than non-obese soldiers. Overall, obesity rates among our primarily officer sample were higher than previous studies, particularly for women. Interventions to address obesity are necessary among military officers to optimize human performance.

Norms about Alcohol Use among US Firefighters.

Background: Problem drinking is a perennial concern in the US fire service. A large literature has documented the importance of addressing alcohol norms in intervention research. The purpose of this study was to explore alcohol norms in a national cohort of firefighters (FFs) to inform intervention development in this occupational group. Methods: Data were from a national online survey of career and volunteer FFs (N = 674). Participants were recruited through national fire service listservs and a database of FFs who had agreed to be contacted for research. Results: When asked about "acceptable" levels of alcohol consumption, FFs on average suggested levels which exceeded public health guidelines. Further, approximately half of career and volunteer FFs believed that, at least under some circumstances, drinking until intoxicated was normative. When asked how long should elapse between a FFs last drink and reporting for duty, the average suggested lag was 11.2 hours (sd = 4.6). However, among male volunteer FFs who reported heavy drinking, the average was 6.68 hours (sd = 4.77). Conclusions: Given the high prevalence of heavy and binge drinking in the fire service, it is not surprising that the alcohol norms found in this study were consistent with a culture of drinking. Participants' reports of alcohol use among their peers were consistent with the actual prevalence of problem drinking. Thus, education and prevention efforts in this occupation should focus on changing norms about alcohol use, including linking heavy drinking to other health and safety issues they face.

Prevalence and predictors of obesity among women in the fire service.

OBJECTIVES: Firefighter health has received a great deal of increased attention over the past decade, but most work has been specific to men in the fire service due to small numbers of women, likely due to challenges with recruitment and retention of women in the fire service. While findings suggest men in the fire service struggle with high rates of overweight and obesity due to a number of occupational challenges, limited data are available on large samples of women firefighters. METHODS: Using snowball sampling techniques, we conducted an online survey of both career (N=2,398) and volunteer (N=781) women firefighters. RESULTS: Rates of obesity for both career (15.4%) and volunteer (31.6%) women firefighters were not only lower than men in the fire service (33.5% career and 43.2% volunteer), but also lower than the general population (41.1%). Women career and volunteer firefighters who engaged in heavy physical activity were less likely to be obese. Being a racial or ethnic minority firefighter was associated with being obese, as was serving more than 20 years in the fire service. CONCLUSION: Findings highlight that women firefighters have been successful in overcoming the occupational risks, such as a challenging nutrition environment, inconsistent schedules, limited time for fitness, and the metabolic impact of shift work, that put firefighters at increased risk for obesity.

Occupational factors and miscarriages in the US fire service: a cross-sectional analysis of women firefighters.

BACKGROUND: Evidence from previous studies suggests that women firefighters have greater risk of some adverse reproductive outcomes. The purpose of this study was to investigate whether women firefighters had greater risk of miscarriage compared to non-firefighters and whether there were occupational factors associated with risk of miscarriage among firefighters. METHODS: We studied pregnancies in the United States fire service using data from the Health and Wellness of Women Firefighters Study (n = 3181). We compared the prevalence of miscarriage among firefighters to published rates among non-firefighters using age-standardized prevalence ratios. We used generalized estimating equations to estimate relative risks (RRs) and 95% confidence intervals (CIs) between occupational factors (employment (career/volunteer), wildland firefighter status (wildland or wildland-urban-interface/structural), shift schedule, fire/rescue calls at pregnancy start) and risk of miscarriage, adjusted for age at pregnancy, education, gravidity, BMI, and smoking. We evaluated if associations varied by age at pregnancy or employment. RESULTS: Among 1074 firefighters and 1864 total pregnancies, 404 pregnancies resulted in miscarriages (22%). Among most recent pregnancies, 138 resulted in miscarriage (13%). Compared to a study of US nurses, firefighters had 2.33 times greater age-standardized prevalence of miscarriage (95% CI 1.96-2.75). Overall, we observed that volunteer firefighters had an increased risk of miscarriage which varied by wildland status (interaction p-value< 0.01). Among structural firefighters, volunteer firefighters had 1.42 times the risk of miscarriage (95% CI 1.11-1.80) compared to career firefighters. Among wildland/wildland-urban-interface firefighters, volunteer firefighters had 2.53 times the risk of miscarriage (95% CI 1.35-4.78) compared to career firefighters. CONCLUSIONS: Age-standardized miscarriage prevalence among firefighters may be greater than non-firefighters and there may be variation in risk of miscarriage by fire service role. Further research is needed to clarify these associations to inform policy and decision-making.

Muscular Strength, Power, and Endurance Adaptations after Two Different University Fitness Classes.

Physical activity (PA) classes help college students add weekly PA, which can help improve health and maintain body weight. Traditional weight training (TWT) can improve strength and aerobic capacity. High-intensity functional training such as CrossFit® (CF) provides time-efficient workouts with both muscle strengthening and aerobic exercises. Limited research has compared these classes for college students. We examined changes in muscular strength, power, and endurance as well as body composition. Participants were 85 healthy college students enrolled in TWT (n = 36, age 22.6 ± 4.1 years, 72.2% male) or CF (n = 49, age 21.8 ± 3.2 years, 55.1% male) classes meeting twice/wk for 8 weeks between October 2017 and May 2018. Baseline and posttest measurements included a vertical jump, grip strength, a 2 min push-up test, a 1 min squat test, height, weight, and a bioelectrical impedance analysis. Although no significant group × time interactions were found, there was a significant main effect of time for push-ups and squats (both p < 0.001). Participants enjoyed the classes and most planned to continue. Both classes improved muscular endurance although no significant differences were found between them. Activity classes provide college students with an option for increasing their weekly PA and help maintain body composition. Future research should examine the benefits from longer or more frequent classes.

A qualitative study to assess perceptions, barriers, and motivators supporting smokeless tobacco cessation in the US fire service.

While firefighters currently have low smoking rates, rates of smokeless tobacco (SLT) use among this population are remarkably high and substantially greater than similar occupational groups, and the general population. This study explored determinants associated with SLT use, barriers to cessation, and motivators for SLT cessation in the fire service. Key informant interviews were conducted in 23 career firefighters who were current (n = 14) and former (n = 9) SLT users from across the U.S. Discussions were recorded and independently coded according to questions and themes. Major themes that developed among firefighters regarding SLT use determinants included positive perceptions of SLT products, social influences from their peers and family members, acceptability of SLT use in the fire service, and a coping resource for job stress. Firefighters discussed several barriers to SLT cessation, including intrapersonal barriers such as SLT use habits and its dependency, concerns about withdrawal symptoms; and social-environmental barriers including lack of support from health and other services providers, and lack of enforcement of existing tobacco policies regarding SLT use. Firefighters also mentioned both internal and external motivators for cessation. Internal motivators included self-motivation and their health concerns while external motivators included friends and family support, incentives or rewards, and price of SLT products. Findings provide unique perspectives from firefighters on factors that influence SLT use and barriers and motivators to SLT cessation. These are insufficiently assessed and considered by the fire service organizations and their health care providers. Thus, the organizations must understand these issues in order to mitigate barriers and motivate the personnel to quit using SLT. Information gained from firefighters who were current and former SLT users can be used to develop an effective, culturally-tailored intervention that is acceptable to fire service personnel.

Development and beta test of a smokeless tobacco cessation program for firefighters.

INTRODUCTION: The prevalence of smokeless tobacco (SLT) use among firefighters is substantially higher than the general population and similar occupational groups. Despite the significant health risks associated with SLT and its impact on occupational readiness, there are no occupationally-tailored SLT education or treatment programs for the fire service. The purpose of this study was to beta test QUIT SPIT!, a self-help SLT cessation program that is culturally tailored for the US fire service and firefighters who are interested in quitting. METHODS: After development and tailoring the QUIT SPIT! SLT cessation program for firefighters, the feasibility and acceptability of the program were evaluated in a sample of eleven SLT-using firefighters who wanted to quit. The primary outcome was a 7-day point prevalence of SLT abstinence measured at 4 and 12 weeks post-enrollment follow-up assessments. RESULTS: Four firefighters reported having quit SLT (7-days point prevalence) at follow-up at 12 weeks. Those who did not achieve SLT abstinence reported reductions in frequency and quantity in SLT use and demonstrated a decrease in nicotine dependence. Firefighters also reported being satisfied with the QUIT SPIT! cessation program. CONCLUSIONS: The results provide strong support for the feasibility and acceptability of the QUIT SPIT! in SLT-using firefighters interested in quitting. The findings provide critical information about the next steps for further development and evaluation of the QUIT SPIT! program.

Cancer Perceptions Among Smokeless Tobacco Users: A Qualitative Study of US Firefighters.

BACKGROUND: Prevalence rates of smokeless tobacco (SLT) use among firefighters are remarkably high and substantially higher than similar occupational groups and the general U.S. population. The purpose of this study was to explore the perspectives of fire service personnel regarding cancer and its associations with tobacco and SLT use. METHODS: This descriptive study used a qualitative approach. Key informant interviews were conducted in 39 career firefighters and fire service administration from across the U.S. Discussion were recorded, transcribed verbatim and transferred to NVivo software for narrative analysis. Topics explored included cancer perceptions, attitudes and beliefs, and cultural factors related to SLT use behaviors. Results: Major themes that emerged among fire service personnel included concerns about cancer and its risk factors including firefighting tasks, such as fire overhaul operations, and from their lifestyle behaviors, such as alcohol and tobacco use. Firefighters also suggested a number of reasons for their increased SLT use, such as fire department tobacco-free policy and fire service culture. CONCLUSION: The current study provides a rich foundation for future research, prevention, and intervention efforts for the fire service and research communities regarding tobacco and SLT use and cancer risk. Additional research on firefighters' cancer beliefs deserves future research in order to improve messaging about the risks of cancer due to firefighting.

Occupationally Tailored, Web-Based, Nutrition and Physical Activity Program for Firefighters: Cluster Randomized Trial and Weight Outcome.

OBJECTIVE: The aim of this study was to determine the efficacy of an occupationally tailored, web-based health and wellness program, The First Twenty® (TF20), for weight change among volunteer firefighters. METHODS: The impact of TF20 on firefighters' 6-month weight change was tested in a cluster, randomized controlled trial, using a crossover design of firefighters in 10 departments. TF20 has web-based nutrition, physical activity, and behavioral health components. RESULTS: An adjusted treatment-induced weight loss from 1.7 to 2.8 lb was observed for all participants and 2.3 to 3.1 lb among overweight and obese participants. An average weight gain was observed among firefighters in the control condition and weight loss for those in the treatment condition. CONCLUSIONS: TF20 supports firefighters' weight loss. Firefighters need wellness interventions to improve nutrition and physical activity given their high prevalence of obesity.

Tobacco Use among Women Firefighters.

OBJECTIVES: Firefighters play a crucial role in protecting the lives and property of the communities they serve. Health and readiness for duty among women firefighters is of great concern because they are a significantly understudied group in this critical occupation. A tobacco-free fire service has been strongly promoted, but there are no published data on the extent and types of tobacco use among women firefighters. METHODS: Data were collected as part of a national online study of the health of women in the fire service. RESULTS: A total of 1,712 women firefighters completed questions regarding tobacco use. Unadjusted smoking and smokeless tobacco rates were 5.1% and 1.2%, respectively. Age standardized smoking rates were lower than those of male firefighters and U.S. adult women. Smokeless tobacco use prevalence was very low compared with male firefighters, but comparable with U.S. adult women. Tobacco users were more likely to have lower education and income and were younger when compared with those who did not use tobacco. There was a strong association between tobacco use and problem and binge drinking. CONCLUSIONS: Current findings suggest that the rates of cigarette and smokeless tobacco use are relatively low among women firefighters. Unhealthy lifestyle behaviors such as problem and binge drinking were strongly associated with tobacco use.

The Prevalence and Health Impacts of Frequent Work Discrimination and Harassment among Women Firefighters in the US Fire Service.

INTRO: Both discrimination and harassment directly impact mental and physical health. Further, workplace discrimination degrades workplace culture and negatively impacts health behaviors, job-related outcomes, and family dynamics. Women represent a small proportion of the fire service and are often the targets of discrimination/harassment, yet little research documents the impact of such experiences. The purpose of this study was to evaluate the relationship between chronic work discrimination and/or harassment and women firefighters' (FFs) physical and mental health, substance abuse, and job efficacy, stress, and satisfaction. METHODS: Snowball sampling was used to solicit participation from women career FFs. Participants completed an online survey regarding physical and mental health, health behavior, job efficacy/stress/satisfaction, and family well-being. Logistic regression examined the impact of work discrimination-harassment severity on dichotomous variables. RESULTS: 1,773 had complete data on their experiences with work-related discrimination and harassment. Women reported experiencing verbal (37.5%) and written (12.9%) harassment, hazing (16.9%), sexual advances (37.4%), and assaults (5.1%) in the fire service. FFs in the highest tertile of work discrimination-harassment severity reported over 40% more poor health days in the last 30 days (OR=1.42; 95%CI=1.33-1.51; p<0.001). Women who experienced moderate and severe discrimination/harassment had negative mental health outcomes including higher prevalence of depressive symptoms, anxiety, and PTSD symptoms. Those who experienced high rates of discrimination and/or harassment also were more likely to report issues with alcohol consumption. CONCLUSION: The impact of discrimination and harassment, related negative physical and mental outcomes, low levels of job satisfaction, and negative impact of these experiences on family/home stress likely take a significant toll on women in the fire service. Findings confirm and extend previous work suggesting there is a need to improve the mental and physical health of women FFs. Future work should examine the prospective relationship between discrimination/harassment and poor health outcomes and potential policies/practices to reduce these negative behaviors.

Sleep, Obesity, and Injury Among US Male Career Firefighters.

OBJECTIVE: The aim of this study was to determine the role of obesity on the association between sleep and on-duty injury among male career firefighters. METHODS: Data on 1419 male career firefighters for this cross-sectional study came from two firefighter cohorts from 2008 to 2013. On-duty injury within the past 6 to 12 months was the dependent variable and getting enough sleep was the independent variable. A multivariable, mixed effect logistic regression model stratified by body mass index (BMI) categories was created to examine the presence of effect measure modification. RESULTS: Only obese firefighters who did not get enough sleep were twice as likely to have an on-duty injury than those who got enough sleep. This association was not significant among normal or overweight firefighters. CONCLUSIONS: Future studies into on-duty injury and sleep should examine body composition as an effect modifier among career firefighters.

Steady State Hydration Levels of Career Firefighters in a Large, Population-Based Sample.

OBJECTIVES: To establish the extent of steady state hypohydration among firefighters and examine factors associated with their hydration status. METHODS: Data on 450 career firefighters from 11 randomly selected fire departments had their body composition, total body water (TBW), and hypohydration status assessed using bioelectrical impedance. Measured height and weight were used to determine body mass index (BMI) and weight classification. RESULTS: The hypohydration rate was 17% and 94% of hypohydrated firefighters were obese. A one-unit increase in BMI was associated with an 83% greater likelihood of being hypohydrated. CONCLUSIONS: This study indicates that steady state hypohydration is a significant issue among obese firefighters. Current hydration policies based on previous reports that most (more than 90%) firefighters are hypohydrated in the steady state should be revisited and additional, confirmatory research in this area should be conducted.

Maternal and Child Health Among Female Firefighters in the U.S.

Objectives Despite increasing attention to the occupational impact of firefighting, little is known specific to the health of women firefighters. In particular, quantitative data is lacking on the impact firefighting has on maternal and child health for women who become pregnant while working as firefighters. Methods A total of 1821 women firefighters responded to requests to complete a self-report survey of questions about pregnancy. Women answered questions about their departments' policies and practices and their own experiences of pregnancy. Those participants who reported a pregnancy while serving as a firefighter were asked detailed questions about their pregnancy and outcomes. Results Female firefighters reported that nearly a quarter of their first pregnancies while in the fire service ended in miscarriage and that increased to a third of pregnancies by the fourth. Rates of pre-term delivery also were high among this population. Conclusions Findings have important implications for policy and practice among women who become pregnant while actively serving in the fire service.

Reproductive Health Concerns Among Female Firefighters.

There has been little research conducted on the reproductive health of female firefighters. The purpose of this study was to determine whether female reproductive health is a concern among firefighters and to identify key associated issues. Eighty-seven United States (US) firefighters participated in focus groups or interviews. Themes were created using grounded theory with NVivo analysis software and a three-phase coding process. The major finding emerging from the study is that female firefighter reproductive health is a significant concern among firefighters.

Alcohol Use and Problem Drinking among Women Firefighters.

OBJECTIVES: Given high levels of occupational stress and toxic exposures, firefighters have a relatively high prevalence of occupationally related medical and mental health disorders compared with the general public. Previous research found high rates of heavy and binge drinking among male firefighters. This study is the first to examine alcohol use among women firefighters. METHODS: Data were collected as part of a national online survey of women, career firefighters. RESULTS: A total of 1,913 women firefighters completed questions regarding alcohol use. Nearly 40% reported binge drinking in the previous month and 4.3% reported driving while intoxicated. Among those who drank, 16.5% screened positive for problem drinking. Problem drinkers were more than 2.5 times as likely to have been diagnosed with depression or have symptoms of posttraumatic stress disorder, and were approximately 40% more likely to have been injured on the job in the previous year, when compared with other women firefighters. Those who screened positive for problem drinking also were significantly less likely to say that they would recommend a fire service career to other women. CONCLUSIONS: As with male firefighters, heavy and problem drinking are prevalent among women firefighters and are associated with negative occupational outcomes.