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.

Excretion of polybrominated diphenyl ethers and AhR activation in breastmilk among firefighters.

Excretion of toxicants accumulated from firefighter exposures through breastmilk represents a potential hazard. We investigated if firefighting exposures could increase the concentration of polybrominated diphenyl ethers (PBDEs) and aryl hydrocarbon receptor (AhR) activation in excreted breastmilk. Firefighters and non-firefighters collected breastmilk samples prior to any firefighting responses (baseline) and at 2, 8, 24, 48, and 72 hours after a structural fire (firefighters only). Five PBDE analytes (BDEs 15, 28, 47, 99, and 153) detected in at least 90% of samples were summed for analyses. The AhR in vitro DR CALUX® bioassay assessed the mixture of dioxin-like compounds and toxicity from breastmilk extracts. Baseline PBDEs and AhR response were compared between firefighters and non-firefighters. Separate linear mixed models assessed changes in sum of PBDEs and AhR response among firefighters over time and effect modification by interior or exterior response was assessed. Baseline PBDE concentrations and AhR responses did not differ between the 21 firefighters and 10 non-firefighters. There were no significant changes in sum of PBDEs or AhR response among firefighters over time post-fire, and no variation by interior or exterior response. Plots of sum of PBDEs and AhR response over time demonstrated individual variation but no consistent pattern. Currently, our novel study results do not support forgoing breastfeeding after a fire exposure. However, given study limitations and the potential hazard of accumulated toxicants from firefighter exposures excreted via breastfeeding, future studies should consider additional contaminants and measures of toxicity by which firefighting may impact maternal and child health.

Perspectives on Engagement With Youth Physical Activity Opportunities in Low-Income, African American, Urban Neighborhoods.

PURPOSE: To identify and describe factors related to low-income, African American youth's participation in neighborhood youth physical activity opportunities (YPAO). APPROACH: Formative research. SETTING: Face-to-face focus groups in New Castle County, Delaware. PARTICIPANTS: Fifty-five adults (parents/guardians of youth, YPAO providers, small business representatives) living and/or working in low-income, African American neighborhoods. METHOD: Nine, 60-90 minute focus groups were conducted from December 2018 through March 2019. Focus group questions were developed a priori and included domains related to neighborhood YPAOs. The domains were awareness of YPAOs, benefits and barriers to providing YPAOs, ways to increase youth participation in YPAOs, and strategies for creating, improving, and sustaining YPAOs. Focus group recordings were transcribed, and thematic analysis was performed to identify themes related to increasing youth participation in YPAOs. RESULTS: Four major themes related to YPAOs emerged: 1) exposure/access, 2) parent buy-in/accountability (e.g., personal values and trust with YPAOs), 3) technology, and 4) increasing a sense of community. Three minor themes included liability, advertising, and schools. Small businesses desired to support YPAOs mainly through non-monetary means, while mutually benefitting from receiving local recognition. CONCLUSION: Developing strategies to incorporate effective community partnerships, creative program ideas with advertising, and active, multisector involvement including small businesses into practice has the potential to increase engagement of low-income, African American youth in YPAOs.

Firefighter occupational factors and the risk of preterm birth: results from a survey of women firefighters in the USA.

OBJECTIVES: Previous research has suggested that women firefighters may have a greater risk of adverse reproductive outcomes compared with non-firefighting women. In this study, we investigated the association between firefighter occupational factors and risk of preterm birth. METHODS: This cross-sectional analysis of US firefighters surveyed in 2017 compared preterm birth among firefighters to non-firefighters using age-at-pregnancy-standardised prevalence ratios. Generalised estimating equations estimated relative risks and 95% CIs between firefighter occupational factors (career or volunteer, wildland status, shift schedule, fire responses, work restriction) and preterm birth risk. We adjusted for age-at-pregnancy, education, gravidity, BMI, and smoking and considered effect modification by age-at-pregnancy and career versus volunteer status. RESULTS: Among 934 women who reported 1356 live births, 12% were preterm (n=161). Preterm birth prevalence among firefighters was 1.41 times greater than non-firefighters (95% CI 1.18 to 1.68). Among wildland and combination wildland/structural firefighters, volunteers had 2.82 times the risk of preterm birth (95% CI 1.19 to 6.67) compared with career firefighters. Firefighters who started restricting their work in the 2nd trimester had a nonsignificant 0.67 times lower risk of preterm birth than those who started in the 3rd trimester or did not restrict work at all (95% CI 0.43 to 1.03). CONCLUSIONS: Firefighters may have greater risk of preterm birth than non-firefighters, which could be influenced by roles in the fire service and work restrictions taken.

Birth defects associated with paternal firefighting in the National Birth Defects Prevention Study.

BACKGROUND: Few studies have evaluated birth defects among children of firefighters. We investigated associations between birth defects and paternal work as a firefighter compared to work in non-firefighting and police officer occupations. METHODS: We analyzed 1997-2011 data from the multi-site case-control National Birth Defects Prevention Study. Cases included fetuses or infants with major structural birth defects and controls included a random sample of live-born infants without major birth defects. Mothers of infants self-reported information about parents' occupations held during pregnancy. We investigated associations between paternal firefighting and birth defect groups using logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Referent groups included families reporting fathers working non-firefighting and police officer jobs. RESULTS: Occupational groups included 227 firefighters, 36,285 non-firefighters, and 433 police officers. Twenty-nine birth defects were analyzed. In adjusted analyses, fathers of children with total anomalous pulmonary venous return (TAPVR; OR = 3.1; 95% CI = 1.1-8.7), cleft palate (OR = 1.8; 95% CI = 1.0-3.3), cleft lip (OR = 2.2; 95% CI = 1.2-4.2), and transverse limb deficiency (OR = 2.2; 95% CI = 1.1-4.7) were more likely than fathers of controls to be firefighters, versus non-firefighters. In police-referent analyses, fathers of children with cleft palate were 2.4 times more likely to be firefighters than fathers of controls (95% CI = 1.1-5.4). CONCLUSIONS: Paternal firefighting may be associated with an elevated risk of birth defects in offspring. Additional studies are warranted to replicate these findings. Further research may contribute to a greater understanding of the reproductive health of firefighters and their families for guiding workplace practices.

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.

Firefighter exposures to potential endocrine disrupting chemicals measured by military-style silicone dog tags.

Studies suggest that exposure to potential endocrine disrupting chemicals (pEDCs) may contribute to adverse health outcomes, but pEDC exposures among firefighters have not been fully characterized. Previously, we demonstrated the military-style silicone dog tag as a personal passive sampling device for assessing polycyclic aromatic hydrocarbon exposures among structural firefighters. This follow-up analysis examined the pEDC exposures based on department call volume, duty shift, and questionnaire variables. Structural firefighters (n = 56) were from one high and one low fire call volume department (Kansas City, MO metropolitan area) and wore separate dog tags while on- and off-duty (ndogtags = 110). The targeted 1530 analyte semi-quantitative screening method was conducted using gas chromatography mass spectrometry (npEDCs = 433). A total of 47 pEDCs were detected, and several less-frequently-detected pEDCs (<75%) were more commonly detected in off- compared to on-duty dog tags (conditional logistic regression). Of the 11 phthalates and fragrances detected most frequently (>75%), off-duty pEDC concentrations were strongly correlated (r = 0.31-0.82, p < 0.05), suggesting co-applications of phthalates and fragrances in consumer products. Questionnaire variables of "regular use of conventional cleaning products" and "fireplace in the home" were associated with select elevated pEDC concentrations by duty shift (paired t-test). This suggested researchers should include detailed questions about consumer product use and home environment when examining personal pEDC exposures.

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.

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.

Discovery of firefighter chemical exposures using military-style silicone dog tags.

Occupational chemical hazards in the fire service are hypothesized to play a role in increased cancer risk, and reliable sampling technologies are necessary for conducting firefighter chemical exposure assessments. This study presents the military-style dog tag as a new configuration of silicone passive sampling device to sample individual firefighters' exposures at one high and one low fire call volume department in the Kansas City, Missouri metropolitan area. The recruited firefighters (n = 56) wore separate dog tags to assess on- and off-duty exposures (ndogtags = 110), for a total of 30 24 h shifts. Using a 63 PAH method (GC-MS/MS), the tags detected 45 unique PAHs, of which 18 have not been previously reported as firefighting exposures. PAH concentrations were higher for on- compared to off-duty tags (0.25 < Cohen's d ≤ 0.80) and for the high compared to the low fire call volume department (0.25 ≤ d < 0.70). Using a 1530 analyte screening method (GC-MS), di-n-butyl phthalate, diisobutyl phthalate, guaiacol, and DEET were commonly detected analytes. The number of fire attacks a firefighter participated in was more strongly correlated with PAH concentrations than firefighter rank or years in the fire service. This suggested that quantitative data should be employed for firefighter exposure assessments, rather than surrogate measures. Because several detected analytes are listed as possible carcinogens, future firefighter exposure studies should consider evaluating complex mixtures to assess individual health risks.

Injury Correlates Among a National Sample of Women in the US Fire Service.

OBJECTIVE: To examine occupational injuries among career women firefighters (FFs). METHODS: A national cross-sectional survey assessed injury prevalence, types, frequencies, and predictors. RESULTS: A total of 3012 women career FFs were enrolled in the study. Almost a third (31.7%) reported at least one occupational injury in the past 12 months. The most common injuries were dislocations, sprains, or strains (59.3%). Racial minority status, self-rated health, body composition, exercise habits, substance use, mental health, and job dissatisfaction were all significant injury correlates. Nearly 43% of injuries resulted in missed workdays. Additionally, 25% reported incurring chronic injuries. CONCLUSIONS: Women FFs reported a high prevalence of occupational injury and a significant percentage reported chronic injuries. These data can inform initiatives to curtail injuries in the fire service and better protect women FFs.

Targeted Assessment and Context-Tailored Implementation of Change Strategies (TACTICS) to increase evidence based psychotherapy in military behavioral health clinics: Design of a cluster-randomized stepped-wedge implementation study.

BACKGROUND: Despite efforts by the U.S. Department of Defense to train behavioral health (BH) providers in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), numerous barriers limit EBP implementation. A context-tailored implementation approach called TACTICS (Targeted Assessment and Context-Tailored Implementation of Change Strategies) holds promise for increasing the use of EBPs such as prolonged exposure therapy (PE) in military treatment facilities. TACTICS combines a needs assessment, a rubric for selecting implementation strategies based on local barriers, an implementation toolkit, and external facilitation to support local champions and their implementation teams in enacting changes. This paper describes the rationale for and design of a study that will evaluate whether TACTICS can increase implementation of PE for PTSD and improve patient outcomes in military BH clinics relative to provider training in PE alone. METHODS: The study is a multi-site, cluster randomized, stepped-wedge trial, with the military treatment facility as the unit of analysis. Eight facilities undergo a provider-training phase, followed by 5 months of TACTICS implementation. The timing of TACTICS at each facility is randomly assigned to begin 9, 14, or 19 months after beginning the provider-training phase. Primary analyses will compare the proportion of PTSD patients receiving PE and patients' mean improvement in PTSD symptoms before and after the onset of TACTICS. DISCUSSION: TACTICS endeavors to balance standardization of empirically-supported implementation strategies with the flexibility of application necessary for success across varied clinical settings. If successful, TACTICS may represent a systematic and scalable method of promoting and supporting EBP implementation. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03663452.

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.