Madeline F. Cannon

Background: World Trade Center (WTC)-exposed Fire Department of the City of New York (FDNY) rescue/recovery workers have an elevated risk of smoking-related morbidity. Despite access to free tobacco cessation treatment, some individuals in this population continue to smoke. In other settings, opt-out treatment approaches increase treatment initiation, but effectiveness in occupational health programs is unclear. Accordingly, we (1) assessed whether an opt-out strategy increases engagement with a Tobacco Cessation Program and (2) identified factors associated with engagement. Methods: This was a randomized trial among FDNY firefighters and Emergency Medical Service (EMS) who self-reported smoking and were eligible for the WTC Health Program Lung Cancer Screening Program. 1:1 randomization occurred prior to contact for opt-out recruitment with Enhanced Care treatment (Opt-Out/Enhanced) or opt-in recruitment with Standard Care treatment (Opt-In/Standard). Opt-Out/Enhanced included proactive outreach and tailored biofeedback during counseling; Opt-In/Standard included participant-initiated engagement and standard counseling. Both groups were offered identical no-cost pharmacotherapy (varenicline). Engagement was defined as: consented enrollment (expressed interest and provided informed consent) and treatment initiation (attendance at ≥1 counseling session). Engagement differences were evaluated using logistic regression; sociodemographic and health-related factors were characterized descriptively without formal testing due to small numbers. Results: Overall, 312 individuals were randomized (Opt-Out/Enhanced, n = 156 and Opt-In/Standard, n = 156). Engagement was low (7.4%). Consented enrollment (n = 23; OR = 3.05; 95% CI = 1.11-9.72) and treatment initiation (n = 18; OR = 2.08; 95% CI = 0.72-6.73) were higher in Opt-Out/Enhanced versus Opt-In/Standard. Treatment initiators had a median age of 60.5 (vs 65.0 years among non-initiators); 38.9% were EMS (vs 18.0%), 22.2% were female (vs 6.9%), 77.8% had a prior cessation attempt (vs 23.5%), and 55.6% had abnormal lung function (vs 32.9%). Participants were too few to analyze cessation outcomes in depth. Conclusions: Despite low engagement overall, opt-out treatment had higher engagement with tobacco cessation treatment. This supports other work that has found opt-out treatment to be encouraged for hard-to-reach populations.

Amyotrophic lateral sclerosis (ALS) is a rare but fatal neurodegenerative disease. Some occupational exposures are associated with ALS. This study evaluated ALS mortality rates in World Trade Center (WTC)-exposed and non-WTC-exposed rescue/recovery workers. Fire department workers who were 18–70 years old on 11 September 2001 (9/11) were included in the study (N = 33,122). Follow-up began on the later of 9/11 or on their hire date, and ended at the earliest death date or 31 December 2023. Cause of death data were obtained from the National Death Index; ALS (specifically motor neuron disease)-related mortality was the primary outcome. Demographic data were obtained from the fire departments’ databases. We estimated standardized mortality ratios (SMRs) and 95% CIs for ALS-related mortality in WTC-exposed and non-WTC-exposed workers using US population rates as a reference. Multivariable-adjusted Poisson regression models estimated relative rates (RRs) and 95% CIs for ALS-related mortality in the WTC-exposed vs. non-WTC-exposed groups. Between 9/11 and 31 December 2023, five WTC-exposed and sixteen non-WTC-exposed participants died of ALS. ALS mortality rates were lower in WTC-exposed than in non-WTC-exposed rescue/recovery workers (RR = 0.54, 95% CI = 0.49–0.60). ALS-related mortality was not elevated in WTC-exposed (SMR = 0.44, 95% CI = 0.14–1.03) or non-WTC-exposed rescue/recovery workers (SMR = 1.06, 95% CI = 0.60–1.72) compared with the US general population. This initial evaluation of ALS in WTC-exposed workers indicates that the risk of ALS death is not increased in this population.

Rationale: Low FEV1 is a biomarker of increased mortality. The association of normal lung function and mortality is not well described. Objectives: To evaluate the FEV1–mortality association among participants with normal lung function. Methods: A total of 10,999 Fire Department of the City of New York (FDNY) responders and 10,901 Third National Health and Nutrition Examination Survey (NHANES III) participants, aged 18–65 years with FEV1 ≥80% predicted, were analyzed, with FEV1 percent predicted calculated using Global Lung Function Initiative Global race-neutral reference equations. Mortality data were obtained from linkages to the National Death Index. Cox proportional hazards models estimated the association between FEV1 and all-cause mortality, controlling for age, sex, race/ethnicity, smoking history, and, for FDNY, work assignment. Cohorts were followed for a maximum of 20.3 years. Measurements and Main Results: We observed 504 deaths (4.6%) of 10,999 for FDNY and 1,237 deaths (9.4% [weighted]) of 10,901 for NHANES III. Relative to FEV1 ≥120% predicted, mortality was significantly higher for FEV1 100–109%, 90–99%, and 80–89% predicted in the FDNY cohort. In the NHANES III cohort, mortality was significantly higher for FEV1 90–99% and 80–89% predicted. Each 10% higher predicted FEV1 was associated with 15% (hazard ratio, 0.85; 95% confidence interval, 0.80–0.91) and 23% (hazard ratio, 0.77; 95% confidence interval, 0.71–0.84) lower mortality for FDNY and NHANES III, respectively. Conclusions: In both cohorts, higher FEV1 is associated with lower mortality, suggesting higher FEV1 is a biomarker of better health. These findings demonstrate that a single cross-sectional measurement of FEV1 is predictive of mortality over two decades, even when FEV1 is in the normal range.