The World Trade Center Health Program: an introduction to best practices.

More than 20 years have elapsed since the September 11, 2001 (9/11) terrorist attacks on the World Trade Center (WTC), Pentagon and at Shanksville, PA. Many persons continue to suffer a variety of physical and mental health conditions following their exposures to a mixture of incompletely characterized toxicants and psychological stressors at the terrorist attack sites. Primary care and specialized clinicians should ask patients who may have been present at any of the 9/11 sites about their 9/11 exposures, especially patients with cancer, respiratory symptoms, chronic rhinosinusitis, gastroesophageal reflux disease, psychiatric symptoms, and substance use disorders. Clinicians, especially those in the NY metropolitan area, should know how to evaluate, diagnose, and treat patients with conditions that could be associated with exposure to the 9/11 attacks and its aftermath. As such, this issue of Archives contains a series of updates to clinical best practices relevant to medical conditions whose treatment is covered by the WTC Health Program. This first paper in the 14-part series describes the purpose of this series, defines the WTC Health Program and its beneficiaries, and explains how relevant Clinical Practice Guidelines were identified. This paper also reminds readers that because physical and mental health conditions are often intertwined, a coordinated approach to care usually works best and referral to health centers affiliated with the WTC Health Program may be necessary, since all such Centers offer multidisciplinary care.

Assessment of Alzheimer's Disease Imaging Biomarkers in World Trade Center Responders with Cognitive Impairment at Midlife.

Purpose Incidence of early onset neurocognitive dysfunction has been reported in World Trade Center (WTC) responders. Ongoing studies are investigating the underlying etiology, as we are concerned that an underlying risk of neurodegenerative dementia may be occurring because of their stressful and neurotoxic exposures to particulate matter when they responded to the search and rescue efforts on September 11, 2001. The purpose of this study is to report preliminary results from two ongoing positron emission tomography (PET)/magnetic resonance imaging (MRI) imaging studies investigating the presence of Alzheimer's disease (AD) biomarkers, such as ß-amyloid, tau, and neurodegeneration, and compare our findings to published norms. Methods We present findings on 12 WTC responders diagnosed with either cognitive impairment (CI) or mild cognitive impairment (MCI), now at midlife, who underwent PET/MRI brain imaging as part of ongoing studies. Six responders with CI received [ 18 F] florbetaben (FBB) to detect ß-amyloidosis and six separate responders with MCI received [ 18 F] flortaucipir (FTP) to detect tauopathy. All 12 responders underwent concomitant MRI scans for gray matter volume analysis of neurodegeneration. Results PET analysis revealed 50% FBB and 50% of FTP scans were clinically read as positive and that 50% of FTP scans identified as consistent with Braak's stage I or II. Furthermore, one responder identified as centiloid positive for AD. Gray matter volumes from MRI analyses were compared with age/sex-matched norms (Neuroquant), identifying abnormally low cortical volumes in the occipital and temporal lobes, as well as the inferior temporal gyri and the entorhinal cortex. Conclusion These preliminary results suggest that WTC responders with neurocognitive dysfunction may be at increased risk for a neurodegenerative dementia process as a result of their exposures at September 11, 2001.

Myeloma precursor disease (MGUS) among rescue and recovery workers exposed to the World Trade Center disaster.

An elevated risk of myeloma precursor disease, monoclonal gammopathy of undetermined significance (MGUS), was identified among Fire Department of the City of New York (FDNY) World Trade Center (WTC)-exposed firefighters. Further investigation was needed to determine if these findings were reproducible in a more heterogeneous WTC-exposed rescue/recovery workers cohort, the Stony Brook University-General Responder Cohort GRC (SBU-GRC). MGUS risk was compared between the cohorts and to published general population estimates from Olmsted County, MN, USA. In this observational seroprevalence study, odds ratios (OR) and age-standardized risk ratios (RR) of MGUS (M-spike and light-chain-MGUS combined), M-spike, and light-chain-MGUS were estimated using logistic regression. Age-standardized prevalences were calculated for white males aged 50-79; RRs were estimated by comparing risk in the WTC-exposed cohort with the Olmsted County screened cohort. SBU-GRC had elevated odds of MGUS compared with FDNY (OR = 1.38; 95%CI = 1.00-1.89). The age-standardized prevalence of MGUS was 9.0/100 persons (95%CI = 7.5-10.6), over two-fold higher than the general population (RR = 2.08; 95%CI = 1.72-2.51); the age-standardized prevalence of light-chain-MGUS was 3.5-fold higher (RR = 3.54; 95%CI = 2.52-4.97). This study adds to mounting evidence supporting an association between WTC/environmental exposures and MGUS among rescue/recovery workers. Access to MGUS screenings for the entire WTC-exposed cohort could allow for treatment interventions that improve survival.

Retrospective Assessment of Risk Factors for Head and Neck Cancer Among World Trade Center General Responders.

Objective: To assess the reliability of a questionnaire designed to reconstruct risk factors for head and neck cancer relative to the 9/11 World Trade Center (WTC) response and over the lifetime. Methods: As part of a nested case-control study, 200 WTC Health Program (WTCHP) General Responder Cohort (GRC) members completed a newly-developed study questionnaire via telephone (with a trained interviewer) or online (self-administered). We assessed agreement between measures of tobacco and alcohol use in our questionnaire results and data collected previously during WTCHP-GRC monitoring visits using Cohens Kappa (κ) and intraclass correlation coefficient (ICC) for categorical and continuous measures, respectively. We compared agreement by disease status, survey mode, and year of WTCHP enrollment. Results: We observed high agreement between measures of lifetime, pre-WTC, and post-WTC smoking prevalence (all κ > 0.85) and smoking duration (all ICC > 0.84). There was moderate agreement between measures of smoking frequency (ICC: 0.61-0.73). Agreement between measures of smoking frequency, but not duration, differed by disease status, and agreement between smoking measures was higher for participants who completed our survey by phone than by web. Among cases, there were no differences based on enrollment in the WTCHP before or after diagnosis. Conclusion: Agreement between measures was generally high, although potential reporting bias and a mode effect that should be considered when interpreting analyses of self-reported data in this population; however differential misclassification appears to be minimal. Our questionnaire may be useful for future studies examining similar behavioral risk factors among disaster-exposed populations.

Epigenome-wide meta-analysis of PTSD across 10 military and civilian cohorts identifies methylation changes in AHRR.

Epigenetic differences may help to distinguish between PTSD cases and trauma-exposed controls. Here, we describe the results of the largest DNA methylation meta-analysis of PTSD to date. Ten cohorts, military and civilian, contribute blood-derived DNA methylation data from 1,896 PTSD cases and trauma-exposed controls. Four CpG sites within the aryl-hydrocarbon receptor repressor (AHRR) associate with PTSD after adjustment for multiple comparisons, with lower DNA methylation in PTSD cases relative to controls. Although AHRR methylation is known to associate with smoking, the AHRR association with PTSD is most pronounced in non-smokers, suggesting the result was independent of smoking status. Evaluation of metabolomics data reveals that AHRR methylation associated with kynurenine levels, which are lower among subjects with PTSD. This study supports epigenetic differences in those with PTSD and suggests a role for decreased kynurenine as a contributor to immune dysregulation in PTSD.

Cancer in General Responders Participating in World Trade Center Health Programs, 2003-2013.

BACKGROUND: Following the September 11, 2001, attacks on the World Trade Center (WTC), thousands of workers were exposed to an array of toxins known to cause adverse health effects, including cancer. This study evaluates cancer incidence in the WTC Health Program General Responder Cohort occurring within 12 years post exposure. METHODS: The study population consisted of 28 729 members of the General Responder Cohort enrolled from cohort inception, July 2002 to December 31, 2013. Standardized incidence ratios (SIRs) were calculated with cancer case inclusion and follow-up starting post September 11, 2001 (unrestricted) and, alternatively, to account for selection bias, with case inclusion and follow-up starting 6 months after enrollment in the WTC Health Program (restricted). Case ascertainment was based on linkage with six state cancer registries. Under the restricted criterion, hazard ratios were estimated using multivariable Cox proportional hazards models for all cancer sites combined and for prostate cancer. RESULTS: Restricted analyses identified 1072 cancers in 999 responders, with elevations in cancer incidence for all cancer sites combined (SIR = 1.09, 95% confidence interval [CI] = 1.02 to 1.16), prostate cancer (SIR = 1.25, 95% CI = 1.11 to 1.40), thyroid cancer (SIR = 2.19, 95% CI = 1.71 to 2.75), and leukemia (SIR = 1.41, 95% CI = 1.01 to 1.92). Cancer incidence was not associated with any WTC exposure index (composite or individual) for all cancer sites combined or for prostate cancer. CONCLUSION: Our analyses show statistically significant elevations in cancer incidence for all cancer sites combined and for prostate and thyroid cancers and leukemia. Multivariable analyses show no association with magnitude or type of exposure.

Risk factors for incident prostate cancer in a cohort of world trade center responders.

BACKGROUND: Despite a relatively young average age and no routine screening, prostate cancer is one of the most common cancers in men who worked at the World Trade Center (WTC) following the 9/11/2001 disaster. This study evaluated whether re-experiencing stressful memories of a traumatic event was associated with prostate cancer incidence. METHODS: Participants were males from one clinical center that monitors the health of first-responders (N = 6857). Monitoring began in July 2002 and occurs annually but does not include prostate cancer screening. Severity of physical exposures and of re-experiencing memories and stress responses were measured at study enrollment using standardized and validated methods in all participants. The outcome was incidence of diagnosed prostate cancer after enrollment (n = 68). Bivariate analyses provided age-adjusted incidence rates (aIR). Cox proportional hazards modeling was used to calculate incidence; hazards ratios (HR) were reported. RESULTS: The mean age of responders on 9/11/2001 was 37.9 years. Prostate cancer incidence was lowest in responders with no re-experiencing stress (aIR = 250.83/100,000 person-years, [233.41-268.25]) and highest in responders with severe re-experiencing stress (aIR = 818.49/100,000 person-years, [801.07-835.91]). Cox proportional hazards regression revealed that re-experiencing the stressful events of 9/11/2001 was associated with increased prostate cancer incidence (HR = 1.96 [1.26-3.05], P = 0.003), even upon adjusting for confounders. CONCLUSIONS: This is the first study to identify a positive association between re-experiencing a traumatic event and prostate cancer incidence. Our results are consistent with recent rodent model evidence demonstrating a direct biological link between stress pathways and prostate tumorigenesis and offer new hypotheses in the causality of prostate cancer.

Risk factors for head and neck cancer in the World Trade Center Health Program General Responder Cohort: results from a nested case-control study.

OBJECTIVES: Head and neck cancers (HNCs) may be among the health consequences of involvement in the World Trade Center (WTC) response on and after 11 September 2001. We conducted a nested case-control study of WTC Health Program (WTCHP) general responders to examine the effects of WTC exposures and behavioural risk factors on HNC. METHODS: We enrolled 64 cases and 136 controls, matched on age, sex and race/ethnicity within risk sets. We assessed tobacco and alcohol use, sexual activity, and occupational exposures prior to, during and after WTC exposure until case diagnosis via questionnaire. We obtained WTC exposure information (duration (first to last day), total days and location of work) from the WTCHP General Responder Data Center. We assessed associations with HNC, and interaction among exposures, using conditional logistic regression. RESULTS: Responders in protective services versus other occupations had increased odds (OR: 2.51, 95% CI 1.09 to 5.82) of HNC. Among those in non-protective services occupations, arriving to the WTC effort on versus after 11 September 2001 was significantly associated with HNC (OR: 3.77, 95% CI 1.00 to 14.11). Duration of work was not significantly associated with HNC. Lifetime and post-WTC years of cigarette smoking and post-WTC number of sex partners were positively and significantly associated with HNC, while alcohol consumption was not. CONCLUSIONS: These findings suggest opportunities for HNC risk factor mitigation (eg, smoking cessation, human papillomavirus vaccination) and contribute to a risk factor profile which may assist WTCHP clinicians with identifying high-risk responders and improve detection and treatment outcomes in this population.

Shortened leukocyte telomere length is associated with reduced pulmonary function and greater subsequent decline in function in a sample of World Trade Center responders.

The objective of this study was to examine whether shorter leukocyte telomere length (LTL) is associated with more rapid pulmonary function decline in a longitudinal study of World Trade Center (WTC) responders. WTC responders (N = 284) participating in a monitoring study underwent blood sampling and were followed prospectively for spirometric outcomes. A single blood sample was taken to measure LTL using southern blotting. Outcomes included percent-predicted one-second forced expiratory volume (FEV1%), forced vital capacity (FVC%), and the FEV1/FVC ratio. In a subset, percent-predicted diffusing capacity (DLCO%) was also measured. Longitudinal modeling examined prospectively collected information over five years since blood was banked was used to examine the rate of change in pulmonary functioning over time. Severity of WTC exposure was assessed. Shorter LTL was associated with lower FEV1% and FVC% at baseline. For example, 29.9% of those with LTL <6.5 kbps had FEV1% <80% whereas only 12.4% of those with LTL ≥6.5 had FEV1% <80% (RR = 2.53, 95%CI = [1.70-3.76]). Lower DLCO% was also significantly associated with shorter LTL. Longitudinal models identified a prospective association between shorter LTL and greater yearly rates of decline in FEV1% (0.46%/year, 95%CI = [0.05-0.87]) and in the FEV1/FVC ratio (0.19%/year, 95%CI = [0.03-0.36]). There were no associations between severity of exposure and either LTL or pulmonary function. Longitudinal analyses revealed that shorter LTL, but not severity of WTC exposures, was associated with poorer pulmonary functioning and with greater subsequent decline in pulmonary functioning over time. These findings are consistent with the idea that shortened LTL may act as a biomarker for enhanced pulmonary vulnerability in the face of acute severe toxic inhalation exposures.

Excess HPV-related head and neck cancer in the world trade center health program general responder cohort.

The World Trade Center (WTC) attacks exposed rescue and recovery workers to a complex mix of toxicants, including carcinogens. our study compared site-specific cancer incidence of head and neck cancers (HNC) from 2003 through 2012 among 33,809 consented WTC General Responder Cohort (GRC) members to the New Jersey State Cancer Registry, using standardized incidence ratios (SIRs). HNC grouped using SEER ICD-O-3 codes into HPV-related (oropharyngeal) and non-related (other oral-nasal; laryngeal) tumors based on anatomical site. For the 73 GRC members identified with HNC, proportional hazard regression assessed the relationship between WTC exposure and other socio-demographic characteristics. An overall excess of HNC was not observed (SIR = 1.00, 95% CI: 0.78, 1.25) but excess cancer was seen in the latest observation period (2009-2012: SIR = 1.4; 95% CI: 1.01, 1.89). A similar temporal pattern was seen for HPV-related oropharyngeal cancer and laryngeal cancer, but not for non-HPV-related sites (oral-nasal cancer). HNC was significantly associated with increasing age (8% per year, 95% CI: 5%, 12%), non-Hispanic white ethnic group-ethnicity (hazard ratio (HR) = 3.51, 95 CI: 1.49, 8.27); there was a borderline association with the 9/11 occupation of military/protective services vs. others (HR = 1.83 95% CI: 0.99, 3.38; p = 0.0504). Caution is needed in interpreting these results given the small number of cases, potential for surveillance bias, and long latency for most cancers. Our findings highlight the need to examine the potentially carcinogenic effects of WTC exposure in the context of other strong risk factors, and the need for continued medical monitoring of WTC responders.

Enhanced exposure assessment and genome-wide DNA methylation in World Trade Center disaster responders.

DNA methylation has emerged as a promising target linking environmental exposures and cancer. The World Trade Center (WTC) responders sustained exposures to potential carcinogens, resulting in an increased risk of cancer. Previous studies of cancer risk in WTC-exposed responders were limited by the deficiency in quantitative and individual information on exposure to carcinogens. The current study introduces a new exposure-ranking index (ERI) for estimating cancer-related acute and chronic exposures, which aimed to improve the ability of future analyses to estimate cancer risk. An epigenome-wide association study based on DNA methylation and a weighted gene co-expression network analysis were carried out to identify cytosine-phosphate-guanosine (CpG) sites, modules of correlated CpG sites, and biological pathways associated with the new ERI. Methylation was profiled on blood samples using Illumina 450K Beadchip. No significant epigenome-wide association was found for ERI at a false discovery rate of 0.05. Several cancer-related pathways emerged in pathway analyses for the top ranking genes from epigenome-wide association study as well as enriched module from the weighted gene co-expression network analysis. The current study was the first DNA methylation study that aimed to identify methylation signature for cancer-related exposure in the WTC population. No CpG sites survived multiple testings adjustment. However, enriched gene sets involved in cancer, were identified in both acute and chronic ERIs, supporting the view that multiple genes play a role in this complex exposure.

Prostate cancer characteristics in the World Trade Center cohort, 2002-2013.

An increased incidence of prostate cancer was reported in three cohorts of World Trade Center (WTC) respondents. It is uncertain whether this increase is because of WTC-related exposures or enhanced surveillance. Prostate cancer cases (2002-2013) were obtained from the WTC Health Program. Age, race, and Gleason score distribution were compared with New York State Cancer Registry cases from the same time period. Multivariate models were adjusted for age and race. Analyses of clinical characteristics of prostate cancer cases within the cohort were also carried out, adjusting for age, race, and WTC exposure categories. WTC respondents had a prostate cancer age-standardized rate ratio of 1.65 [95% confidence interval (CI): 1.37-1.93] compared with New York State; age-specific ratios were highest for ages 30-49 (2.28; 95% CI: 1.51-3.43), 70-74 (2.05; 95% CI: 1.03-4.10), and 80-84 years (5.65; 95% CI: 1.41-22.58). High WTC exposure was associated with advanced clinical stage (5.58; 95% CI: 1.05-29.76; Ptrend=0.03). WTC respondents continue to have a higher prostate cancer rate compared with New York State as a whole. Respondents with a higher WTC exposure level may have had more advanced clinical stage of prostate cancer.

Respiratory problems and anxiety sensitivity in smoking lapse among treatment seeking smokers.

PURPOSE: The current study examined whether the interaction of lower respiratory symptoms and anxiety sensitivity is related to smoking lapse in the context of smoking cessation. METHOD: Participants were adult daily smokers (N=60) exposed to the World Trade Center (WTC) disaster who were in a smoking cessation treatment program (75.0% male, 50.6years old [SD=9.2], and current smoking rate was 17.6 cigarettes per day (SD=10.6). RESULTS: Results indicated that the interaction between lower respiratory symptoms and anxiety sensitivity was a significant predictor of greater risk for lapse (i.e., lower survival time; B=0.005, OR=1.01, p=0.039). Follow-up analysis showed that greater respiratory symptoms were a significant predictor of lapse risk among those with high (B=0.116, OR=1.12, p=0.025), but not those with low (B=-0.048, OR=0.95, p=0.322), levels of anxiety sensitivity. DISCUSSION: The findings from the current study suggest that smokers with greater respiratory symptoms and higher levels of anxiety sensitivity may be associated with early lapse to smoking following smoking cessation treatment. Future work has the potential to inform the development of tailored cessation interventions for smokers who experience varying levels of lower respiratory symptoms and anxiety sensitivity.

Pathway from PTSD to respiratory health: Longitudinal evidence from a psychosocial intervention.

OBJECTIVE: Respiratory illness and posttraumatic stress disorder (PTSD) are common debilitating conditions that frequently co-occur. Observational studies indicate that PTSD, independently of smoking, is a major risk and maintenance factor for lower respiratory symptoms (LRS). The current study experimentally tested this etiologic pathway by investigating whether LRS can be reduced by treating PTSD symptoms. METHOD: Ninety daily smokers exposed to the World Trade Center (WTC) disaster (mean age 50 years, 28% female; 68% White) completed 8-session group-based weekly comprehensive trauma management and smoking cessation treatment that focused on skills to alleviate PTSD symptoms. LRS, PTSD symptoms, and smoking were assessed weekly. Data was analyzed using multilevel models of within-person associations between LRS, PTSD symptoms, smoking, and treatment dose across 8 weekly sessions with concurrent and lagged outcomes. RESULTS: LRS improved significantly with treatment (reduction of .50 standard deviations). Reduction in PTSD symptoms uniquely predicted improvement in LRS at consecutive sessions 1 week apart and fully accounted for the treatment effect on LRS. The effect of PTSD symptoms was stronger than that of smoking, and the only effect to remain significant when both entered the model. Notably, reduction in LRS did not predict future improvement in PTSD symptoms. CONCLUSIONS: The results are in line with the etiologic pathway suggesting that PTSD symptoms are a risk and maintenance factor for chronic LRS and that treatment of PTSD can help to alleviate LRS in trauma-exposed populations. PTSD is emerging as a novel and important treatment target for chronic respiratory problems. (PsycINFO Database Record

Understanding the Connection Between Posttraumatic Stress Symptoms and Respiratory Problems: Contributions of Anxiety Sensitivity.

Respiratory problems and posttraumatic stress disorder (PTSD) are the signature health consequences associated with the September 11, 2001 (9/11), World Trade Center disaster and frequently co-occur. The reasons for this comorbidity, however, remain unknown. Anxiety sensitivity is a transdiagnostic trait that is associated with both PTSD and respiratory symptoms. The present study explored whether anxiety sensitivity could explain the experience of respiratory symptoms in trauma-exposed smokers with PTSD symptoms. Participants (N = 135; Mage = 49.18 years, SD = 10.01) were 9/11-exposed daily smokers. Cross-sectional self-report measures were used to assess PTSD symptoms, anxiety sensitivity, and respiratory symptoms. After controlling for covariates and PTSD symptoms, anxiety sensitivity accounted for significant additional variance in respiratory symptoms (ΔR2 = .04 to .08). This effect was specific to the somatic concerns dimension (ß = .29, p = .020); somatic concerns contributed significantly to accounting for the overlap between PTSD and respiratory symptoms, b = 0.03, 95% CI [0.01, 0.07]. These findings suggest that the somatic dimension of anxiety sensitivity is important in understanding respiratory symptoms in individuals with PTSD symptoms. These findings also suggest that it may be critical to address anxiety sensitivity when treating patients with comorbid respiratory problems and PTSD.

Temporal variability of urinary cadmium in spot urine samples and first morning voids.

Cadmium is a carcinogenic heavy metal. Urinary levels of cadmium are considered to be an indicator of long-term body burden, as cadmium accumulates in the kidneys and has a half-life of at least 10 years. However, the temporal stability of the biomarker in urine samples from a non-occupationally exposed population has not been rigorously established. We used repeated measurements of urinary cadmium (U-Cd) in spot urine samples and first morning voids from two separate cohorts, to assess the temporal stability of the samples. Urine samples from two cohorts including individuals of both sexes were measured for cadmium and creatinine. The first cohort (Home Observation of Perinatal Exposure (HOPE)) consisted of 21 never-smokers, who provided four first morning urine samples 2-5 days apart, and one additional sample roughly 1 month later. The second cohort (World Trade Center-Health Program (WTC-HP)) consisted of 78 individuals, including 52 never-smokers, 22 former smokers and 4 current smokers, who provided 2 spot urine samples 6 months apart, on average. Intra-class correlation was computed for groups of replicates from each individual to assess temporal variability. The median creatinine-adjusted U-Cd level (0.19 and 0.21 µg/g in the HOPE and WTC-HP, respectively) was similar to levels recorded in the United States by the National Health and Nutrition Examination Survey. The intra-class correlation (ICC) was high (0.76 and 0.78 for HOPE and WTC-HP, respectively) and similar between cohorts, irrespective of whether samples were collected days or months apart. Both single spot or first morning urine cadmium samples show good to excellent reproducibility in low-exposure populations.

Trauma-Focused Smoking Cessation for Smokers Exposed to the World Trade Center Disaster: A Randomized Clinical Trial.

INTRODUCTION: The main objective was to evaluate the efficacy of an 8-session, group-based comprehensive smoking cessation and trauma management (CSC-T) treatment among daily smokers (≥5 cigarettes/day) exposed to the World Trade Center (WTC) disaster with elevated WTC-related post-traumatic stress disorder (PTSD) symptoms. METHODS: Participants (N = 90) were randomly assigned to CSC-T (N = 44; 63.6% white; 27.3% female; mean age = 51.32 ± 7.87) or comprehensive smoking cessation (CSC) alone (N = 46; 71.7% white; 28.3% female; mean age = 48.74 ± 10.66), which was comparable in length and time. Assessments included a diagnostic clinical interview and self-report measures of PTSD and respiratory symptoms, and smoking behavior, and biologically confirmed smoking abstinence. Evaluations occurred at a baseline visit, each treatment session, and at 1-, 2-, 4-, 12-, and 26-weeks post-treatment. RESULTS: The two treatments did not differ in regard to PTSD symptom improvement. After quit day (week 6), the two groups had similar 7-day (~15%) and 6-month (~20%) abstinence rates as well as average number of cigarettes smoked, and PTSD and respiratory symptoms. CONCLUSIONS: It is possible that the Cognitive Behavioral Therapy skills specific to quitting smoking, group-based support, and degree of therapist contact, that were available in both treatments may have played a role in equalizing the abstinence rates between the two conditions. Although the current study found no evidence that the CSC-T was superior to the CSC alone treatment, the abstinence rates observed were high relative to previous trials of smokers with diagnosed PTSD. Further development of smoking cessation programs tailored to the needs of smokers with PTSD symptoms continues to be needed. IMPLICATIONS: This study suggests that a CSC program aids in smoking abstinence for smokers with PTSD symptoms and that incorporating trauma management skills, may not add additional benefits for abstinence and PTSD and respiratory symptom relief. Further work is needed to improve smoking cessation efforts for smokers with PTSD symptoms.

Posttraumatic stress symptoms and body mass index among World Trade Center disaster-exposed smokers: A preliminary examination of the role of anxiety sensitivity.

Among individuals exposed to the World Trade Center (WTC) disaster on September 11, 2001, posttraumatic stress disorder (PTSD) and symptoms are both common and associated with increased cigarette smoking and body mass. However, there is little information on the specific processes underlying the relationship of PTSD symptoms with body mass. The current study is an initial exploratory test of anxiety sensitivity, the fear of internal bodily sensations, as a possible mechanism linking PTSD symptom severity and body mass index (BMI). Participants were 147 adult daily smokers (34.0% female) exposed to the WTC disaster (via rescue/recovery work or direct witness). The direct and indirect associations between PTSD symptom severity and BMI via anxiety sensitivity (total score and subscales of physical, cognitive, and social concerns) were examined. PTSD symptom severity was related to BMI indirectly via anxiety sensitivity; this effect was specific to physical concerns about the meaning of bodily sensations. Interventions focusing on anxiety sensitivity reduction (specifically addressing physical concerns about bodily sensations) may be useful in addressing elevated BMI among trauma-exposed persons.

Mortality among World Trade Center rescue and recovery workers, 2002-2011.

BACKGROUND: Rescue and recovery workers responding to the 2001 collapse of the World Trade Center (WTC) sustained exposures to toxic chemicals and have elevated rates of multiple morbidities. METHODS: Using data from the World Trade Center Health Program and the National Death Index for 2002-2011, we examined standardized mortality ratios (SMR) and proportional cancer mortality ratios (PCMR) with indirect standardization for age, sex, race, and calendar year to the U.S. general population, as well as associations between WTC-related environmental exposures and all-cause mortality. RESULTS: We identified 330 deaths among 28,918 responders (SMR 0.43, 95%CI 0.39-0.48). No cause-specific SMRs were meaningfully elevated. PCMRs were elevated for neoplasms of lymphatic and hematopoietic tissue (PCMR 1.76, 95%CI 1.06-2.75). Mortality hazard ratios showed no linear trend with exposure. CONCLUSIONS: Consistent with a healthy worker effect, all-cause mortality among responders was not elevated. There was no clear association between intensity and duration of exposure and mortality. Surveillance is needed to monitor the proportionally higher cancer mortality attributed to lymphatic/hematopoietic neoplasms.

Smoking to Regulate Negative Affect: Disentangling the Relationship Between Posttraumatic Stress and Emotional Disorder Symptoms, Nicotine Dependence, and Cessation-Related Problems.

INTRODUCTION: Posttraumatic stress disorder (PTSD) is associated with various aspects of cigarette smoking, including higher levels of nicotine dependence and cessation difficulties. Affect-regulatory smoking motives are thought to, in part, underlie the association between emotional disorders such as PTSD and smoking maintenance, although few studies have empirically tested this possibility. METHODS: Data were analyzed from 135 treatment-seeking smokers who were directly exposed to the World Trade Center disaster on September 11, 2001. We modeled the direct effect of 9/11 PTSD symptom severity on nicotine dependence, perceived barriers to smoking cessation, and severity of problematic symptoms experienced during prior cessation attempts. We also examined the indirect effect of PTSD on these outcomes via negative affect reduction smoking motives. Parallel models were constructed for additional emotional disorder symptoms, including panic and depressive symptoms. RESULTS: PTSD symptom severity was associated with nicotine dependence and perceived barriers to cessation, but not problems during prior quit attempts indirectly via negative affect reduction smoking motives. Panic and depressive symptoms both had significant indirect effects, via negative affect reduction smoking motives, on all three criterion variables. CONCLUSIONS: Affect-regulatory smoking motives appear to underlie associations between the symptoms of emotional disorders such as PTSD, panic, and depression in terms of smoking dependence and certain cessation-related criterion variables. IMPLICATIONS: Overall, this investigation suggests negative affect reduction smoking motives help to explain the relationship of PTSD, depression, and panic symptoms to nicotine dependence, severity of problems experienced during prior quit attempts and perceived barriers to cessation. These results highlight the importance of assessing motivations for smoking in the context of cessation treatment, especially among those with emotional disorder symptoms. Future interventions might seek to utilize motivational interviewing and cognitive restructuring techniques to address coping-oriented motives for smoking, in addition to skills for managing negative affect, as a means of improving quit outcomes.