Women who smoke during pregnancy are more likely to be referred to an obstetrician during pregnancy and birth: results from a cohort study.

BACKGROUND: Women who smoke during pregnancy make less use of prenatal care; the relation of smoking behavior with the use of other forms of maternal healthcare is unknown. The objective of this study is to investigate the association between women's smoking behavior and their use of healthcare during pregnancy, birth and six weeks postpartum. METHODS: We analyzed data from the Dutch Midwifery Case Registration System (VeCaS), period 2012-2019. We included women with a known smoking status, singleton pregnancies, and who had their first appointment before 24 weeks of gestation with the primary care midwife. We compared three groups: non-smokers, early stoppers (stopped smoking in the first trimester), and late- or non-stoppers (stopped smoking after the first trimester or continued smoking). Descriptive statistics were used to report maternal healthcare utilization (during pregnancy, birth and six weeks postpartum), statistical differences between the groups were calculated with Kruskal-Wallis tests. Multivariable logistic regression was conducted to assess the association between smoking behavior and referrals to primary, secondary or tertiary care. RESULTS: We included 41 088 pregnant women. The groups differed significantly on maternal healthcare utilization. The late- or non-stoppers initiated prenatal care later and had less face-to-face consultations with primary care midwives during pregnancy. Compared to the non-smokers, the early- and late- or non-stoppers were statistically signficiantly more likely to be referred to the obstetrician during pregnancy and birth. Postpartum, the early- and late- or non-stoppers were statistically signficantly less likely to be referred to the obstetrician compared to the non-smokers. CONCLUSIONS: Although the early- and late- or non-stoppers initiated prenatal care later than the non-smokers, they did receive adequate prenatal care (according to the recommendations). The results suggest that not smoking during pregnancy may decrease the likelihood of referral to secondary or tertiary care. The large population of smokers being referred during pregnancy underlines the important role of the collaboration between healthcare professionals in primary and secondary or tertiary care. They need to be more aware of the importance of smoking as a medical and as a non-medical risk factor.

The needs of women and their partners regarding professional smoking cessation support during pregnancy: A qualitative study.

BACKGROUND: Despite the health risks of smoking, some women continue during pregnancy. Professional smoking cessation support has shown to be effective in increasing the proportion of pregnant women who quit smoking. However, few women actually make use of professional support. AIM: To investigate the needs of women and their partners for professional smoking cessation support during pregnancy. METHODS: Semi-structured interviews were held with pregnant women and women who recently gave birth who smoked or quit smoking during pregnancy, and their partners, living in the north of the Netherlands. Recruitment was done via Facebook, LinkedIn, food banks, baby stores and healthcare professionals. The interviews were recorded, transcribed and thematically analysed. RESULTS: 28 interviews were conducted, 23 with pregnant women and women who recently gave birth, and five with partners of the women. The following themes were identified: 1) understanding women's needs, 2) responsibility without criticism, and 3) women and their social network. These themes reflect that women need support from an involved and understanding healthcare professional, who holds women responsible for smoking cessation but refrains from criticism. Women also prefer involvement of their social network in the professional support. CONCLUSION: For tailored support, the Dutch guideline for professional smoking cessation support may need some adaptations. The adaptations and recommendations, e.g. to involve women and their partners in the development of guidelines, might also be valuable for other countries. Women prefer healthcare professionals to address smoking cessation in a neutral way and to respect their autonomy in the decision to stop smoking.

Reference values and early determinants of intra-abdominal fat mass in primary school children.

BACKGROUND: Intra-abdominal fat (IAF) is a valuable predictor of cardiovascular morbidity. However, neither reference values nor determinants are known in children. METHODS: IAF was assessed as sonographically measured intra-abdominal depth in 1,046 children [median age 7.6 years, interquartile range (IQR) 7.2-7.9; 54% boys] of the URMEL-ICE study. RESULTS: The intraclass correlation coefficient for intraobserver agreement was 0.93. The median IAF showed a significant gender difference (boys: 54.6 mm, IQR 50.1-59.3, vs. girls: 51.7 mm, IQR 46.3-56.4; p < 0.001). Age- and gender-specific centiles were generated. IAF showed a positive correlation to systolic blood pressure [regression coefficient (ß) = 0.24 mm Hg/mm; p < 0.001] and a negative correlation to HDL cholesterol (ß = -0.01 mmol/l/mm; p < 0.001). IAF showed a positive association with increased paternal and maternal BMI (ß = 0.28 mm/kg/m(2) and 0.27 mm/kg/m(2); p < 0.001), increased weight gain in the first 2 years of life (ß = 3.04 mm; p < 0.001), and maternal smoking during pregnancy (ß = 2.4 mm; p = 0.001). Increased parental education was negatively associated with IAF (maternal: ß = -0.65 mm/degree; p = 0.004, and paternal: ß = -0.61 mm/degree; p = 0.002). CONCLUSION: Sonography was a reliable tool to estimate IAF. Factors influencing IAF included rapid infant weight gain, smoking during pregnancy, and parental BMI and education. Since IAF showed an association with cardiovascular risk factors even in prepubertal children, it might become a valuable predictor of cardiovascular vulnerability.

Secular changes of anthropometric measures for the past 30 years in South-West Germany.

We investigated long-term changes in weight and skinfold thicknesses in German schoolchildren. In 2006, anthropometric measures were collected after a standardized protocol among 1079 children within the Ulm Research on Metabolism, Exercise and Lifestyle in children (URMEL-ICE) study. Data were compared with historical data (1975-1976). In URMEL-ICE, prevalence of overweight (IOTF criteria) was 16.5% (boys) and 17.3% (girls) and of obesity 3.5 and 3.6%, respectively. Compared with historical data the number of children above the 90th percentile(1975/76) increased statistically significantly for weight (approximately 150% both sexes), for subscapular (boys 288%, girls 206%) and triceps skinfold thickness (boys 460%, girls 413%). Statistically significant increases above the 50th percentile(1975/76) were found: weight 36 and 26%, subscapular 43 and 60% and triceps skinfold thickness 63 and 69% for boys and girls, respectively. Body fat among 6- to 9-year-old children increased dramatically within 30 years. Moreover, our data suggest substantial changes in body composition among normal-weight children towards an increased body fat mass.

How well do questionnaires perform compared with physical examination in detecting flexural eczema? Findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two.

BACKGROUND: Questionnaires are widely used in epidemiological studies to measure eczema symptom prevalence, but there are concerns regarding their accuracy if used as a diagnostic tool. OBJECTIVES: To compare the performance of a validated eczema symptom questionnaire and a standardized skin examination protocol employed in the second phase of the International Study of Asthma and Allergies in Childhood (ISAAC). METHODS: A total of 30,358 schoolchildren aged 8-12 years from 18 countries were examined for flexural eczema. Parents also completed an eczema symptom questionnaire. We compared prevalence estimates at the population level based on the questionnaire vs. physical examination. We also compared the skin examination and the ISAAC questionnaire in making a diagnosis of flexural eczema. RESULTS: The point prevalences for flexural eczema at centre level based on a single examination were lower than the questionnaire-based 12-month period prevalences (mean centre prevalence 3.9% vs. 9.4%). Correlation between prevalences of both outcome measures was high (r = 0.77, P < 0.001). At the individual level, questionnaire-derived symptoms of 'persistent flexural eczema in the past 12 months' missed < 10% of cases of flexural eczema detected on physical examination. However, between 33% and 100% of questionnaire-based symptoms of 'persistent flexural eczema in the past 12 months' were not confirmed on examination. CONCLUSIONS: ISAAC questionnaire-derived symptom prevalences are sufficiently precise for comparisons between populations. Where diagnostic precision at the individual level is important, questionnaires should be validated and potentially modified in those populations beforehand, or a standardized skin examination protocol should be used.

Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC).

BACKGROUND: Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC) measured the global prevalence and severity of asthma symptoms in children. METHODS: A cross-sectional questionnaire survey of 798 685 children aged 13-14 years from 233 centres in 97 countries, and 388 811 children aged 6-7 years from 144 centres in 61 countries, was conducted between 2000 and 2003 in >90% of the centres. RESULTS: The prevalence of wheeze in the past 12 months (current wheeze) ranged from 0.8% in Tibet (China) to 32.6% in Wellington (New Zealand) in the 13-14 year olds, and from 2.4% in Jodhpur (India) to 37.6% in Costa Rica in the 6-7 year olds. The prevalence of symptoms of severe asthma, defined as >or=4 attacks of wheeze or >or=1 night per week sleep disturbance from wheeze or wheeze affecting speech in the past 12 months, ranged from 0.1% in Pune (India) to 16% in Costa Rica in the 13-14 year olds and from 0% to 20.3% in the same two centres, respectively, in the 6-7 year olds. Ecological economic analyses revealed a significant trend towards a higher prevalence of current wheeze in centres in higher income countries in both age groups, but this trend was reversed for the prevalence of severe symptoms among current wheezers, especially in the older age group. CONCLUSION: Wide variations exist in the symptom prevalence of childhood asthma worldwide. Although asthma symptoms tend to be more prevalent in more affluent countries, they appear to be more severe in less affluent countries.

Effect of breastfeeding on asthma, lung function and bronchial hyperreactivity in ISAAC Phase II.

The association between breastfeeding and wheezing, lung function and atopy was evaluated in the International Study of Asthma and Allergy in Childhood (ISAAC) Phase II. Cross-sectional studies were performed in 27 centres in 20 countries. Information on disease and exposure factors was collected by parental questionnaires. Data from 54,000 randomly selected school children (aged 8-12 yrs, 31,759 with skin prick testing) and a stratified subsample (n = 4,888) were used for testing the correlation of breastfeeding with bronchial hyperreactivity and lung function. Random effect models for meta-analysis were applied to calculate combined odds ratios (ORs). Any breastfeeding was associated with less wheeze both in affluent (adjusted OR (OR(adj)) 0.87, 95% confidence interval (CI) 0.78-0.97) and nonaffluent countries (OR(adj) 0.80, 95% CI 0.68-0.94). Further analyses revealed that this was true only for nonatopic wheeze in nonaffluent countries (OR(adj) 0.69, 95% CI 0.53-0.90). Breastfeeding was not associated with atopic wheeze and objective measures of allergy in both affluent and nonaffluent countries. In contrast, breastfeeding was associated with higher predicted forced expiratory volume in one second in affluent countries only (mean ratio 1.11, 95% CI 1.02-1.20). Breastfeeding is associated with protection against nonatopic wheeze, which becomes particularly evident in nonaffluent countries. Overall, breastfeeding was not related to any measure of allergy. These findings may explain some of the controversy regarding breastfeeding, since the direction of the association with breastfeeding depends on the predominating wheeze phenotype (e.g. atopic, nonatopic).

A multi-centre study of candidate genes for wheeze and allergy: the International Study of Asthma and Allergies in Childhood Phase 2.

BACKGROUND: Common polymorphisms have been identified in genes suspected to play a role in asthma. We investigated their associations with wheeze and allergy in a case-control sample from Phase 2 of the International Study of Asthma and Allergies in Childhood. METHODS: We compared 1105 wheezing and 3137 non-wheezing children aged 8-12 years from 17 study centres in 13 countries. Genotyping of 55 candidate single nucleotide polymorphisms (SNPs) in 14 genes was performed using the Sequenom System. Logistic regression models were fitted separately for each centre and each SNP. A combined per allele odds ratio and measures of heterogeneity between centres were derived by random effects meta-analysis. RESULTS: Significant associations with wheeze in the past year were detected in only four genes (IL4R, TLR4, MS4A2, TLR9, P<0.05), with per allele odds ratios generally <1.3. Variants in IL4R and TLR4 were also related to allergen-specific IgE, while polymorphisms in FCER1B (MS4A2) and TLR9 were not. There were also highly significant associations (P<0.001) between SPINK5 variants and visible eczema (but not IgE levels) and between IL13 variants and total IgE. Heterogeneity of effects across centres was rare, despite differences in allele frequencies. CONCLUSIONS: Despite the biological plausibility of IgE-related mechanisms in asthma, very few of the tested candidates showed evidence of association with both wheeze and increased IgE levels. We were unable to confirm associations of the positional candidates DPP10 and PHF11 with wheeze, although our study had ample power to detect the expected associations of IL13 variants with IgE and SPINK5 variants with eczema.

International variation in prevalence of rhinitis and its relationship with sensitisation to perennial and seasonal allergens.

The relative importance of atopy in the aetiology of rhinitis is largely unknown. The present study investigated the geographical variations in rhinitis in relation to atopy. The cross-sectional study involved 54,178 children (aged 8-12 yrs) from 30 study centres in 22 countries worldwide. Symptoms of rhinoconjunctivitis and rhinitis without conjunctivitis in the last 12 months were reported in parental questionnaires and children were skin-prick tested. The prevalence of rhinoconjunctivitis and rhinitis without conjunctivitis varied widely (1.5-24.5% and 1.4-45.2%, respectively). For rhinoconjunctivitis, the population attributable fraction (PAF) varied 0-71% for a positive skin-prick test to one or more seasonal allergens and 0-41% for perennial allergens. The PAF for sensitisation to seasonal and perennial allergens was higher in affluent countries (36 and 25%, respectively) than nonaffluent countries (1.3 and 12.6%, respectively). For rhinitis without conjunctivitis, the PAF for perennial allergens was 8 and 4% for affluent and nonaffluent countries, respectively. No significant PAF was found for seasonal allergens. Overall, atopy explained only a limited proportion of rhinitis symptoms, suggesting that the importance of other environmental factors has been under emphasised, particularly in less affluent countries. Atopy seems to be only marginally relevant for rhinitis without conjunctivitis, which seems mainly to reflect nonatopic rhinitis.

STAT1 gene variations, IgE regulation and atopy.

BACKGROUND: Signal transducer and activator of transcription 1 (STAT1), an intracellular signal transducer and activator of transcription centrally involved in many inflammatory pathways, was recently suggested to play an important role in allergy related immune responses. AIM: Thus, we investigated the effect of polymorphisms in the STAT1 gene on the development of atopic sensitization and allergic diseases. METHODS: Haplotype tagging single nucleotide polymorphisms (SNPs) previously described in the STAT1 gene were genotyped by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry technology in a cross-sectional study population of 3099 German children recruited and phenotyped by the International Study of Asthma and Allergy in Childhood, phase II (ISAAC II). Effects of single SNPs and haplotypes were studied using SAS/Genetics and Haploview. RESULTS: The polymorphism C39134A (rs3771300), located in a potentially cis acting regulatory element in STAT1 intron 24, was inversely related to atopy measured by skin prick test, total and specific serum IgE levels while no effect on atopic disease risk was observed. CONCLUSION: Our results indicate that STAT1 SNP C39134A may protect from atopic sensitization. Because of its location in a highly conserved noncoding sequence near a putative GATA3 binding site, this polymorphism represents an interesting target for further studies.

Leisure time activity and new onset of wheezing during adolescence.

Asthma prevalence is increasing in adult and paediatric patients. In the present study, the association between different leisure time activities and new onset of wheezing was analysed in adolescents aged 16-18 yrs taking part in a questionnaire-based follow-up of the International Study on Asthma and Allergies in Childhood in Munich and Dresden, Germany. Of the 3,785 adolescents who took part in the follow-up (76% response), 2,910 adolescents without earlier episodes of wheezing in childhood were included in the analyses. Of these, 330 (11.3%) reported new onset of wheeze during the previous 12 months. In the bivariate analyses, exercising more than once per week or performing computer work >1 h.day(-1) were inversely related to new onset of wheeze. In contrast, visiting discotheques on a regular basis increased the risk of new onset of wheeze (12.9 versus 9.9%). The observed inverse relationship between physical activity and new onset of wheeze was not an independent effect but mediated by differences in active smoking. The association between physical activity and new onset of wheeze disappeared when active smoking was taken into account. However, the present data do not allow for determining whether smoking operated as a confounder or as an intermediate factor, i.e. whether physical activities prevented active smoking.

First months of employment and new onset of rhinitis in adolescents.

The aim of the present study was to investigate the incidence of rhinitis in adolescents, taking into account the duration and type of employment in holiday and vocational jobs, and to study latency until development of symptoms. Participants of the International Study of Asthma and Allergies in Childhood (ISAAC)-II study in Munich and Dresden (Germany), who were enrolled in 1995, were re-contacted by a postal questionnaire in 2002 (aged 16-18 yrs). The questionnaire focused on allergic rhinitis, type and duration of all jobs, and potential confounders. All jobs held for >/=8 h.week(-1) and >/=1 month were coded and occupational exposure was assigned by a job-exposure matrix. Out of the 3,785 participants, 964 reported an employment history. The median (25th-75th percentile) duration of employment was 10 (1-16) months. After adjusting for potential confounders, those working in high-risk occupations (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.0-2.1) had an increased risk for new onset of rhinitis, especially those exposed to low molecular weight agents (OR 1.8, 95% CI 1.1-2.8). The incidence of rhinitis was highest among those currently employed in a high-risk job for <10 months. Teenagers who start working in high-risk occupations have a higher incidence of rhinitis compared with those not working. This increased risk might occur early on during employment.

Nonatopic asthma is associated with helminth infections and bronchiolitis in poor children.

Asthma is common in urban centres in Latin America, but atopic asthma may not be the main phenotype among children. Helminth infections are highly prevalent in poor populations, and it was hypothesised that they attenuate allergic asthma, whereas other factors are related to the expression of a nonatopic wheeze/asthma phenotype. A total of 1,982 children from Southern Brazil with a mean+/-sd age of 10.1+/-0.76 yrs completed asthma questionnaires, and 1,011 were evaluated for intestinal parasites and atopy using skin-prick tests (SPTs). Wheeze in the previous 12 months was reported by 25.6%, and 9.3% showed current asthma; 13% were SPT-positive and 19.1% were positive for any helminths. Most children with either wheeze or asthma were SPT-negative; however, severe wheeze was more prevalent among the atopic minority. Helminth infections were inversely associated with positive SPT results. Bronchiolitis before the age of 2 yrs was the major independent risk factor for asthma at age 10 yrs; high-load Ascaris infection, a family history of asthma and positive SPT results were also asthma risk factors. Most asthma and wheeze are of the nonatopic phenotype, suggesting that some helminths may exert an attenuating effect on the expression of the atopic portion of the disease, whereas viral bronchiolitis predisposes more specifically to recurrent airway symptoms.

Polymorphisms in eosinophil pathway genes, asthma and atopy.

BACKGROUND: Eosinophilic inflammation is considered to play an important role in the development as well as in the perpetuation of asthma. As eosinophil production and survival is under genetic control we investigated whether polymorphisms in eosinophil regulation pathway genes (IL-3, IL-5, GM-CSF and their respective enhancers and receptors) may influence the development of atopic diseases. METHODS: In two large study populations of children, the German part of the International Study of Asthma and Allergy in Childhood (ISAAC II) and the German Multicentre Atopy Study (MAS), 3099 and 824 children, seven polymorphisms previously associated with the development of atopic diseases were genotyped: two in and around the GM-CSF gene (Ile117Thr and T3085G), one in IL-3 (Pro27Ser), in IL-5 (C-746T), and in the IL-5 high affinity receptor chain IL-5R (G-80A) and two in the common receptor chain CSFR2b for IL-3, IL-5, and GM-CSF (Asp312Asn and Glu249Gln). Statistical analyses were performed using chi-squared tests and variance analyses. Gene by gene interactions were evaluated in logistic regression models. RESULTS: The T allele at position -746 in the IL-5 gene was significantly protective for atopy in the ISAAC II population (P = 0.006). Furthermore, the risk for atopic asthma was decreased in carriers of the T allele (P = 0.036) and evidence for interaction with the enhancer polymorphism 3085 bp 3' of GM-CSF was detected. CONCLUSIONS: IL-5 C-746T influenced atopic outcomes and showed evidence for gene by gene interaction. No significant associations were found with all other tested polymorphisms in the eosinophil regulation pathway after correction for multiple testing.

Do respiratory symptoms predict job choices in teenagers?

Existing guidelines advise adolescents with asthma and allergies against high-risk occupations. The aim of the current authors' analyses was to investigate the resulting self-selection in a prospective cohort study. The participants of Phase II of the International Study of Asthma and Allergies in Childhood in Germany (aged 9-11 yrs at baseline) were re-contacted after 7 yrs (response rate was 77%) and were asked to complete a questionnaire, which included items on atopic diseases. The subjects were also asked about the type of job they would like to have in the future (preferred job choice). Exposure to agents with potential asthma risk was evaluated using a job exposure matrix. The analyses were restricted to those in school-based vocational training programmes without occupational exposures. A total of 33% of subjects chose jobs with high asthma risk, 23% selected low asthma risk jobs and the remaining adolescents indicated jobs without known asthma risk (reference category). There were no statistically significant associations between asthma, allergic rhinitis or atopic dermatitis and selecting jobs with asthma risk. Participants with allergic rhinitis tended to select high risk jobs less frequently. In conclusion, self-selection into low risk jobs seems to play a minor role in teenagers with asthma or allergies.

Smoking and the incidence of asthma during adolescence: results of a large cohort study in Germany.

BACKGROUND: The association between smoking and asthma or wheeze has been extensively studied in cross sectional studies, but evidence from large prospective cohort studies on the incidence of asthma during adolescence is scarce. METHODS: We report data from a cohort study in two German cities, Dresden and Munich. The study population (n = 2936) was first studied in 1995/6 at age 9-11 years as part of phase II of the International Study of Asthma and Allergies in Childhood (ISAAC II) and followed up in 2002/3. At baseline the parents completed a questionnaire and children underwent clinical examination and blood sampling. At follow up the young adults completed questionnaires on respiratory health, living, and exposure conditions. Incidence risk ratios (IRR) were calculated and adjusted for potential confounders using a modified Poisson regression approach. RESULTS: The adjusted IRR for incident wheeze for active smokers compared with non-smokers was 2.30 (95% confidence interval (CI) 1.88 to 2.82). The adjusted IRR was slightly higher for incident wheeze without a cold (2.76, 95% CI 1.99 to 3.84) and the incidence of diagnosed asthma (2.56, 95% CI 1.55 to 4.21). Analysis of duration and intensity of active smoking indicated dose dependent associations. Stratified analyses showed that the risk of incident wheeze without a cold in atopic smokers increased with decreasing plasma alpha(1)-antitrypsin levels at baseline (1.64, 95% CI 1.22 to 2.20 per interquartile range). CONCLUSIONS: Active smoking is an important risk factor for the incidence of asthma during adolescence. Relatively lower plasma levels of alpha(1)-antitrypsin, although well above currently accepted thresholds, may increase susceptibility to respiratory disease among atopic smokers.

Fasting blood glucose and cancer risk in a cohort of more than 140,000 adults in Austria.

AIMS/HYPOTHESIS: We investigated relations between fasting blood glucose and the incidence of cancer. METHODS: A population-based cohort of more than 140,000 Austrian adults (63,585 men, 77,228 women) was followed over an average of 8.4 years. Incident cancer (other than non-melanoma skin cancers) was ascertained by a population-based cancer registry (n=5,212). Cox proportional-hazards models were used to estimate hazard rate ratios (HR) stratified for age and adjusted for smoking, occupational group and body mass index. RESULTS: The highest fasting blood glucose category (> or =7.0 mmol/l) was weakly associated with all cancers combined (HR 1.20; 95% CI, 1.03-1.39 in men and 1.28; 95% CI, 1.08-1.53 in women) relative to the reference level (4.2-5.2 mmol/l). The strongest association was found for liver cancer in men (HR 4.58; 95% CI, 1.81-11.62). Positive associations between fasting hyperglycaemia (6.1-6.9 or > or =7.0 mmol/l) and cancer incidence were also observed for non-Hodgkin's lymphoma in men, and for colorectal and bladder cancer in women. Breast cancer in women diagnosed at or after age 65 was also associated with fasting blood glucose > or =7.0 mmol/l. Positive associations with glucose values >5.3 mmol/l were noted for thyroid cancer, gallbladder/bile duct cancer and multiple myeloma in men and women combined. CONCLUSIONS/INTERPRETATION: These findings provide further evidence that elevated blood glucose is associated with the incidence of several types of cancer in men and women.

Cancer mortality in German carbon black workers 1976-98.

BACKGROUND: Few studies have investigated cancer risks in carbon black workers and the findings were inconclusive. METHODS: The current study explores the mortality of a cohort of 1535 male German blue-collar workers employed at a carbon black manufacturing plant for at least one year between 1960 and 1998. Vital status and causes of death were assessed for the period 1976-98. Occupational histories and information on smoking were abstracted from company records. Standardised mortality ratios (SMR) and Poisson regression models were calculated. RESULTS: The SMRs for all cause mortality (observed deaths (obs) 332, SMR 120, 95% CI 108 to 134), and mortality from lung cancer (obs 50, SMR 218, 95% CI 161 to 287) were increased using national rates as reference. Comparisons to regional rates from the federal state gave SMRs of 120 (95% CI 107 to 133) and 183 (95% CI 136 to 241), respectively. However, there was no apparent dose response relationship between lung cancer mortality and several indicators of occupational exposure, including years of employment and carbon black exposure. CONCLUSIONS: The mortality from lung cancer among German carbon black workers was increased. The high lung cancer SMR can not fully be explained by selection, smoking, or other occupational risk factors, but the results also provide little evidence for an effect of carbon black exposure.