RESPIRATORY HEALTH IMPACTS IN THE ENTERTAINMENT INDUSTRY FROM EXPOSURE TO THEATRICAL SMOKES AND FOGS
by
SUNIL CHARLES VARUGHESE
H.B.Sc, The University of Toronto
A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
in
THE FACULTY OF GRADUATE STUDIES
School of Occupational and Environmental Hygiene
We accept this thesis as conforming to the required standard
THE UNIVERSITY OF BRITISH COLUMBIA
November 2002
© Sunil Charles Varughese, 2002 In presenting this thesis in partial fulfilment of the requirements for an advanced
degree at the University of British Columbia, I agree that the Library shall make it
freely available for reference and study. I further agree that permission for extensive
copying of this thesis for scholarly purposes may be granted by the head of my
department or by his or her representatives. It is understood that copying or
publication of this thesis for financial gain shall not be allowed without my written
permission.
Department
The University of British Columbia Vancouver, Canada
DE-6 (2/88) Abstract
The potential for respiratory health impacts from exposure to theatrical smokes and fogs (glycol or mineral oil aerosols) in the entertainment industry has raised concern among employees and performers and given rise to compensation claims. One hundred and one entertainment industry workers in British Columbia were studied in live theatre, film production, music concerts and other venues where theatrical smokes and fogs was used on the study day. Sites consisted of a convenience sample and participation was greater than 70%.
An American Thoracic Society based questionnaire with additional questions on skin and voice symptoms and exposure history was used to assess chronic effects. Cross-shift spirometry, an acute symptoms questionnaire and exposure monitoring on the study day were used in assessing effects from acute exposure. Monitoring data and histories were used in estimating cumulative exposure to theatrical smokes and fogs over the past 2 years.
Compared to controls, the entertainment industry group had reduced FEV1 (p<0.05), and increased dyspnea (p<0.05), work-related chest tightness (p<0.05), work-related sneezing (p<0.05) and work-related nasal symptoms (p<0.05).
For the entertainment industry group only, internal multivariable analysis to assess symptom relationships to cumulative exposure over the past 2 years (1000 mg/m3-hrs) showed the following for work-related symptoms (OR, 95% Cf): cough. 1.8 (1.1, 3.1), phlegm 2.4 (1.1, 5.3), wheezing 1.4 (0.9, 2.1), chest tightness 1.2 (0.8, 1.9), nasal symptoms 0.9 (0.7,1.3), and skin rashes 1.2 (0.7, 2.1). Glycol-based theatrical smoke was associated with acute symptoms as follows (OR, 95%CI): cough 2.7 (0.5, 14.5), chest 2.0 (0.6, 6.7), 2 or more nose/throat/voice 2.4 (0.5, 9.7), dryness 4.9 (1.7, 13.8), central nervous system 3.9 (1.4, 11.3), and irritative eye 3.2 (1.0, 10.6).
No significant associations were found between cumulative exposure and FVC and FEV1. However, percent FEV1/FVC was significantly associated with cumulative exposure (B=1.17, p<0.05). For cross-shift lung function changes mineral oil-based theatrical smoke was negatively associated with FEV1 (B=-1.35, p=0.1).
Overall, the results indicate that exposure to theatrical smokes and fogs is causing non• specific respiratory irritation and increasing the risk for chronic airflow obstruction among BC entertainment industry employees. Table of Contents
Abstract ii Table of Contents iii List of Tables v Acknowledgements V1 1 Introduction • 1 2 Background 3 2.1 Historical Use 3 2.2 Current Use 3 2.3 Current Theatrical Smoke Generation Methods 5 3 Literature Review 8 3.1 Previous Studies on Theatrical Smokes and Fogs 10 3.2 Respiratory and Mucous Membrane effects from exposure to Glycols found in Fog Fluid 18 3.3 Allergic Contact Sensitization related to Glycols 21 3.4 Respiratory Health Effects from Inhalation Exposure to Mineral Oil 25 3.5 Respiratory and Mucous Membrane Irritation from Aldehydes 26 4 Objectives 28 5 Methods 29 5.1 Selection of Study Sites 29 5.2 Exposure Monitoring 31 5.2.1 Area Exposure Measurements 31 5.2.2 Personal Exposure Measurements 33 5.3 Health Effects 35 5.3.1 Participation, study design 35 5.3.2 Ethics, informed consent 35 5.3.3 Questionnaires 36 5.3.4 Physiologic testing 37 5.3.5 Comparison data 38 5.3.6 Data management and analysis 39 6 Health Effects Study Results 51 6.1 Participation and Characteristics of Study Participants 51 6.2 Characteristics of Work 53 6.3 Correlations among potential explanatory variables 59 6.4 Respiratory Health Indicators-Entertainment Industry Group vs. Comparison Group 59 6.5 Respiratory Health Indicators in Relation to Theatrical Smoke Exposures: Entertainment Industry Group Only 62 6.6 Dermal Health Indicators 65 6.7 Acute Symptoms 65 6.8 Cross-Shift Lung Function Results 68 7 Discussion 70 7.1 Overview 70 7.2 Interpretation of Chronic Respiratory Symptoms 71 7.3 Interpretation of Lung Function Results 73 7.4 Interpretation of Acute Symptoms 74 7.5 Strengths of the Study 75 7.6 Limitations of the Study 77 7.7 Summary 79 7.8 Comparison of Risks and Recommendations 86 Appendix A :Consent Form and Questionnaires 89 Appendix B: Correlations and T Test results for variables considered in models 128
m List of Tables
Table 3-1 Physical-Chemical Properties of Glycols Found in Theatrical Smokes 24 Table 5-1 Description of Multivariable Models 47 Table 6-1 Participation 51 Table 6-2 Demographics 52 Table 6-3 Health History 53 Table 6-4 Set Location on Current Production 54 Table 6-5 Respirator Useage at Work 54 Table 6-6 Job Titles 55 Table 6-7 Work Duration Characteristics for Current Production 56 Table 6-8 Personal Exposure on Sampling Day 57 Table 6-9 Self-reported Exposure Variables for Sampling Day 57 Table 6-10 Calculated Variables for Self-reported Past Smoke Exposure 58 Table 6-11 Chronic Symptoms 60 Table 6-12 Lung Function Results 61 Table 6-13 Odds Ratios for Multivariable Models for Reported Work-Related Respiratory Symptoms 63 Table 6-14 Linear Regression Multivariable Models for Lung Function Results 64 Table 6-15 Odds Ratio for Reported Skin Symptoms 65 Table 6-16 Acute Symptoms Prevalence 66 Table 6-17 Acute Symptoms by Grouping 67 Table 6-18 Odds Ratios for Multivariable Models for Acute Symptoms 67 Table 6-19 Multivariable Cross-Shift Change in Lung Function 69 Table 7-1 Comparison of Findings with Previous Studies 85
IV Acknowledgements
I would like to thank the members of my thesis committee Kay Teschke and Mike Brauer. I would especially like to thank my supervisor, Susan Kennedy for her guidance and incredible ability to keep me motivated throughout this whole process.
Thanks to Yat Chow for collecting and preparing the exposure data and assisting me with work on the sets. Thanks also goes to Barbara Karlen for technical training and much support throughout the project, and Victor Leung for lab support. A special thanks goes to SHAPE, Linda Kinney, Rob Jackes, Marty Clausen, Ian Pratt, Mark Thompson, Byron Lonneberg, Jason Hartley, Jim Rhodes, Mike Price, Prem Marimathu, Kathy Gilroy- Sereda, all of the study participants, and the many production managers and technical directors who gave permission to conduct our study on their productions.
I would also like to thank my friends in BC and in Ontario and my family for their much support and words of encouragement along the way.
V 1 Introduction
The use of theatrical smokes and fogs which will also be referred to as 'smokes' or 'fogs' has been a concern in the entertainment industry for many years. Compensation claims have been filed by employees in the entertainment industry who have been exposed to theatrical smoke. Although it is difficult to estimate the number of claims filed worldwide, an article in the San Francisco Chronicle referred to 7 worker's compensation claims filed since 1990 with the San Francisco Opera Association claiming throat irritation from exposure to theatrical smokes and fog (Russell 2001). These performers believed that they have suffered adverse respiratory effects from exposure to fogs. The issue of theatrical smokes and fogs is a complex one as they create important visual effects on a production.
Two previous studies on theatrical smokes and fogs had found associations between exposure to theatrical smokes and fogs and self-reported nasal, throat, and respiratory symptoms but these studies only focused on Broadway Musicals in New York (Burr, Van
Guilder et al. 1994; Moline, Golden et al. 2000). Difficulty exists in generalizing these findings to other production types as exposures in musicals may differ from exposures in movie/television productions and music concerts. Musicals, lasting only a few hours would be expected to have shorter duration exposures to peak levels of theatrical smokes and fogs while movie/television productions and music concerts would be expected to have lower peak exposures over the course of a workday which can range from 10-18 hours. Uncertainty still exists about exposure scenarios in these production types within the entertainment industry.
1 Researchers at the School of Occupational and Environmental Hygiene at the University of British Columbia were approached by Safety and Health in Arts, Production, and
Entertainment (SHAPE) about conducting a study investigating the use of theatrical smokes and fogs. SHAPE is a health and safety agency that deals with the entertainment industry in British Columbia and has representatives from both labour and management.
For the first phase of the study, special effects technicians (those operating smoke machines) were surveyed about the materials and equipment that they used to create special effects smoke. The second phase involved a cross-sectional study for assessing acute (pre-exposure versus post-exposure symptom and lung function results) and chronic health effects, exposures and potential associations between the two. For health effects, a respiratory and skin symptoms assessment along with lung function testing were conducted. This thesis describes the health effects component of this cross-sectional study.
2 2 Background
Background information on historical and current use of theatrical fogs was obtained from an Entertainment and Services Technology Association (ESTA) publication.
2.1 Historical Use
Theatrical smokes have been around since the time of the ancient Greeks, who created smoke by burning pitch and resinous torches. However, the methods of producing smokes have changed since that time. It was not uncommon for Shakespearean audiences to encounter sulfurous fumes wafting across the stage as producers turned to atmospheric effects to enhance the experience for audiences. The persisting desire to create an altered reality which fascinates audiences, has led to continued use of theatrical smokes (ESTA, 1998). Based on discussions with industry personnel and reports in trade publications, in the past materials such as petroleum distillates, zinc chloride, ammonium chloride, mixing of acids and bases, pressurized water, talc powder, diatomaceous earth, flour, aluminum, fragrances, dyes, and burned organic materials (frankincense, rosin, charcoal, cigarettes and cigars, paper, napthalene, anthracene, bee gum, and rubber tires) were used to create theatrical smokes and fogs (ESTA, 1998).
2.2 Current Use
There are many reasons that smokes are used today and include: making beams of light and lasers visible, allowing performers to disappear, creating a washed out appearance to
3 colors for film, simulating fires, and enhancing the believability of an alternative world by the use of fogs lying low to the ground.
Over the past several years, the motion picture and television industry has grown in BC and the rest of Canada. According to the BC film commission, 50 000 British Columbia residents rely on the film industry to make a living; 20 000 fulltime and 30 000 part time and spinoff jobs have been created by this industry. Special effects technicians, directors, actors, production assistants, standins, props technicians, makeup artists, camera persons, and many other people working on a production could all encounter theatrical fogs in their work environment.
This exposure to theatrical smoke is not only confined to motion picture and television.
Production personnel and performers employed in live productions may also work in smoke-filled environments at times. The growing number and popularity of music concerts, live theatre, opera, night clubs, and raves have led to a larger proportion of the general public being exposed to theatrical smokes. Some large-scale video arcades also use theatrical smokes. In addition to production crews, service workers at these venues may be routinely exposed to theatrical smoke. Depending on their frequency of attendance, certain patrons may also face a routine exposure to smokes. These could include compromised people such as children, the elderly and those with pre-existing respiratory problems. Smoke generation is also used by the military to conceal troop movements and mask navy vessels, and in commercial aviation emergency testing
(Palmer 1990; Weislander, Norback et al. 2001).
4 Despite the variation in work environments where smokes would be used, similar methods and materials are used according to interviews with special effects technicians.
Because of the limited amount of work carried out in this area, there is an uncertainty about the safety of these products.
2.3 Current Theatrical Smoke Generation Methods
As previously mentioned, while the use of fogs continues, the techniques and products have changed over the years. Today, various glycol/water mixtures and food grade mineral oils are most commonly used and occasionally dry ice and liquid nitrogen are used in creating low lying fogs.
The most common effect-generating techniques for glycol-based or mineral oil-based fog fluids create suspended liquid aerosols (fogs) using mechanical or thermal methods.
Mechanical methods include crackers which differ from petroleum crackers in the petroleum industry. A cracker consists of a high-pressure air compressor attached to a dispersion system which may consist of some brass fittings with tiny holes in the end and works much like an atomizer. The dispersion system is placed in a vat of what is usually food-grade mineral oil. As the air comes out of the holes in the brass fitting, the surface of the oil breaks and tiny droplets of oil (10-20+ um diameter) are dispersed into the air.
These crackers are commonly used in outdoor music concerts as they produce a long- lasting fog. Crackers which use glycol-based fluids also exist and are known as "water crackers". Ultrasonic fog generation involves using an array of ultrasonic transducers
5 submerged below the surface of a glycol/water mixture. The fluid is broken into small droplets which rise above the fluid and are then moved out of the machine by a fan.
Thermal methods use either pump propelled or gas propelled fog machines, both of which move a fluid into a heat exchanger to produce a fog. Pump-propelled systems use glycol-based fluids and involve pumping the fluid from the reservoir to the heat exchanger that has been heated to a temperature at which the fluid will vaporize, which is usually less than 340°C. The increase in pressure from the fluid's expansion into vapor causes it to move out of the front of the machine where it then mixes with cooler air to form an aerosol. Gas-propelled systems involve a fluid that is usually glycol-based. This fluid is then mixed with a non-flammable gas from a pressurized container that propels it into the heat exchanger that is pre-heated to the boiling temperature of the fluid. The fluids expansion into vapor pushes it out of the front of the machine as an opaque aerosol resulting in a fog with fine aerosol droplets (0.5-4 um). Gas-propelled systems create a longer-lasting fog when compared with pump-propelled systems.
In addition to the concerns over exposure to fog aerosols produced by the methods mentioned above, thermal methods provide an additional area of concern related to exposures. Although the temperature of the heat exchangers is not supposed to exceed
340°C (ESTA, 1998), the decomposition temperature for glycerol is 290°C (Merriman,
1988). This gives rise to the potential for thermal degradation products such as acrolein, acetaldehyde and formaldehyde (Merriman, 1988). If these smokes produce adverse effects related to a chemical-specific mechanism and sufficient levels of these
6 degradation products are formed, the degradation products could lead to a greater toxicity compared to the parent solution.
Inhalation is the main route of exposure to the many components of theatrical smokes for performers and crews. Dermal exposure could result from spills while filling reservoirs.
In many situations once fogs are generated, especially in the case of methods and materials that create long-lasting fogs, exposures may last for the entire workday. While the total mass concentration would decrease over time, as larger droplets settle, the smallest droplets can remain in the air for hours to days (Wilson and Spengler, 1996).
7 3 Literature Review
The literature review focused on 2 main aspects:
• Previous epidemiological studies conducted on theatrical smokes and fogs
• Toxicology literature available on the chemical components of fog fluid including
both human and animal studies
Search Strategy
Searches were conducted using the following databases:
• Medline (1966-current)
• Toxline
• Registry of Toxic Effects of Chemical Substances (RTECS)
• CHEMINFO
• Hazardous Substances Database (HSDB)
To determine the likely chemical components used in theatrical smokes and fogs, MSDS sheets from the 2 major manufacturer's (LeMaitre and Rosco) and a Special Effects
Supply company within Vancouver were collected. From these MSDS sheets, it was determined that dipropylene glycol, triethylene glycol, glycerol, propylene glycol, 1,3- butylene glycol, polyethylene glycol and white mineral oil USP were the chemicals which were most likely to be found in fog fluid. The following keywords and combinations of keywords were used.
• Theatrical smokes and fogs
8 • glycols
• Smokes and fogs
• Glycol fog/ glycol smoke
• Mineral oil fog/mineral oil smoke
In addition, in order to find papers which may be related to the toxicology of the chemical components of smokes and fogs, the following keywords were combined with
"inhalation", "respiratory", "skin", "allergic contact dermatitis", and "contact dermatitis":
• dipropylene glycol/CAS 25265-71-8
• triethylene glycol/CAS 112-27-6
• glycerol/glycerin/CAS 56-81-5
• propylene glycol/CAS 57-55-6
• 1,3-butylene glycol/CAS 107-88-0
• polyethylene glycol 200/CAS 25322-68-3
• white mineral oil/food grade mineral oil/white mineral oil USP
• glycol/glycols
• mineral oil
9 3.1 Previous Studies on Theatrical Smokes and Fogs
In total, 4 studies were found which looked at health effects from exposure to theatrical smokes and fogs.
The National Institute for Occupational Safety and Health Study
Two studies were conducted by the National Institute for Occupational Safety and Health
(NIOSH) (Burr, Van Guilder et al. 1994). In the first study, the analytical method for glycol exposure was found to be inadequate in quantifying glycol exposures.
Study #1: Initial Survey 1991
Methods
Four Broadway productions using theatrical smokes in 1991 were selected for study.
Personal and General Area Sampling, and a questionnaire addressing the frequency and severity of respiratory and irritant symptoms following exposure to theatrical smoke were conducted during dress rehearsals. Personal air samples and questionnaire administration focused on actors exposed to theatrical smokes. However, a limited number of personal air samples were collected on electricians, carpenters, and other personnel who may have been exposed to theatrical smoke during a performance. It was determined that the
NIOSH Sampling and Analytical Method #550 used for ethylene glycol was not appropriate for identifying and quantifying other glycols found in theatrical smoke as interference could have occurred with other glycol analytes. Questionnaires were also administered to actors in five Broadway productions in which no theatrical smoke was
10 used, in order to determine if the prevalence of symptoms differed in actors working on theatrical 'smokes' productions versus 'non-smoke' productions.
Respiratory symptoms, nasal symptoms, and mucous membrane symptoms were the focus of the questionnaire. A health history part of the questionnaire asked of smoking status, preexisting respiratory conditions, and phlegm from chest. In addition, subjects were asked how often in the last week they experienced respiratory, mucous membrane and central nervous system symptoms during a performance, how severe the symptoms were, and whether the symptoms changed when not at work.
Results
In 1991 for the initial survey, symptom questionnaires were received from 134 actors
(60% participation) in 4 Broadway productions using smoke and 90 actors (40% participation) in 5 control (non-smoke) productions. When compared to the actors working in 'non-smoke' productions, actors working in 'smoke' productions reported a significantly greater prevalence of respiratory, nasal, and mucous membrane symptoms during performances for the week prior to the survey. While it was not possible to quantify glycol exposure levels because of problems with the analytical method, air samples were collected for mineral oil mist during one production. Concentrations of mineral oil mist ranged up to 1.35 mg/m3 time-weighted average over the duration of the play.
11 Study #2: Follow-Up Survey 1993
Methods
A followup survey was conducted in two phases that was designed to evaluate the relationship between acute changes in lung function and 'fog' exposure status among those performers reporting symptoms consistent with occupational asthma. A screening questionnaire which was designed to identify performers with symptoms suggestive of occupational asthma, was administered to three 'smoke' productions and three 'non- smoke' productions (Phase I). The symptomatic performers and a random sample of non-symptomatic performers were invited to participate in a followup case-control study
(Phase II). Participants were asked to complete self-administered questionnaires which addressed medical and work history and were also asked to use portable flow meters on their own to determine peak expiratory flow rates (PEFR).
Exposure monitoring consisted of General Area air samples collected during live performances on three theatrical smoke productions. Sampling was conducted for glycols, aldehydes (acrolein and formaldehyde), mineral oil mist (for one production using mineral oil), and volatile organic compounds.
Results
There were 68 non-symptomatic performers and 37 symptomatic performers and a 62% participation rate with 65 of 105 performers submitting at least a partial questionnaire or
PEFR information. There were five persons with theatrical worked-related asthma (had asthma-like symptoms and abnormal peak-flow meter results). Of these 5, three were
12 exposed to smokes during the study. Of the 60 participants who did not have theatrical work-related asthma according to the definition, 16 people previously identified as having symptoms suggestive of occupational asthma were excluded from further study.
For the analysis, 45 performers (27 smoke-exposed, 18 non-exposed) without case- defined occupational asthma remained. Performers who were cases were not more likely to have been exposed to theatrical smoke when compared to persons not meeting this case definition. The odds ratio (OR) was 1.0 for the association between occupational asthma and being smoke-exposed.
For the exposure monitoring, ethylene glycol which was sampled in two productions, was found at concentrations of 0.4 mg/m3 or less. Propylene glycol, detected in samples from all three productions was found in concentrations ranging from <0.01mg/m3 to 1.9 mg/m3. Triethylene glycol and 1,3-butylene glycol were detected in only one production.
Triethylene glycol ranged in concentration from <0.04 to 3.7 mg/m3 while 1,3-butylene glycol ranged from 0.16 to 2.1 mg/m3. Formaldehyde concentrations ranged from <0.002 to 0.04 parts per million (ppm), typical of those levels found in non-industrial workplaces. Acrolein was not detected on any of the general area samples (Minimum
Detectable Concentration 0.016 mg/m3). Oil mist concentrations were 0.13 mg/m3.
Thermal desorption analysis revealed that only 2 samples contained even modest concentrations of VOCs and levels of compounds detected on the other samples were very low. The major compounds detected were C9-C12 aliphatic hydrocarbons and
C9H12 alkyl benzenes (trimethyl benzenes, propyl benzenes, etc). Other compounds
13 identified on the samples included 1,1,1-trichloroethane, acetaldehyde, acetone, isopropanol, toluene, limonene, siloxanes, and perchloroethylene.
Study #3: The Actor's Equity Study
The second study conducted by Mount Sinai School of Medicine and ENVIRON
International was a longitudinal epidemiologic study consisting of health effects monitoring and an exposure assessment through the use of a Job Exposure Matrix
(Moline, Golden et al. 2000). Medical evaluations consisting of a vocal quality assessment, pulmonary function tests and direct visualization of the vocal cords before and after performances were conducted over the course of the study.
Methods
This study chose local irritant effects of the respiratory tract and eyes as the health endpoint to be assessed. The study consisted of 3 phases. In phase 1, a baseline questionnaire was administered to obtain demographic, health, and work information including exposure to theatrical smoke in previous productions. Prevalence of symptoms in the respiratory tract and eyes in the previous month was also reported. Phase 2 consisted of a longitudinal followup. Three daily checklists were to be completed for three one-month periods with a two month hiatus in between. Actors were asked to record day of performance, number of performances, roles played and the perceived level of effects used. Information was collected on physical and vocal conditioning activities, cigarette smoking, perceived stress level at work and away from work. This phase provided information about occurrence of self-reported symptoms in three one-month
14 periods among actors with differing levels of exposure to either single or multiple theatrical effects in a given production. Phase 3 consisted of 4 medical evaluations: 1. a computerized acoustic voice analysis, 2. perceptual vocal rating, 3. spirometry, 4. videoendoscopy/videostroboscopy of the vocal cords. These evaluations were conducted before and after performances on actors recruited from shows across the range of exposures.
Results
The average time weighted concentrations in the Broadway productions was 0.73 mg/m for glycols and 0.74 mg/m3 for mineral oil. Maximum measured short-term exposure levels to glycols which are often used as a quick burst were as low as 0.37 mg/m for one production but ranged from 20-46 mg/m3 for the other 5 productions. These short-term exposure levels were weighted according to inhalation rates typical for actors to obtain potential peak concentrations. The potential peak concentration was still 0.37 mg/m3 for the lowest production but the range of the other 5 productions changed to 32-160 mg/m3.
The study found that symptoms (respiratory, throat, nasal) were associated with peak exposures to glycols. An increase in irritated throat symptoms were found among actors with the highest mineral oil exposures. Although no significant acute changes were detected in vocal cord appearance, peak glycol exposures were associated with a minor impact on voice quality and reported symptoms of mucous membrane irritation. There were significant associations between overall increases in throat symptoms with increasing glycol exposure. Symptoms such as coated vocal cords, hoarseness, voice
15 change and nasal irritation were associated with increasing glycol exposure. Actors with longer exposures to peak levels of glycols had a statistically significant increased rate of inflammation of throat or vocal cords.
Actors having the highest exposures to mineral oil, >3.65 mg/m3 (greater than 5 times the average level on a Broadway production) had statistically significant decreases in pre performance percentage-predicted Forced Vital Capacity (FVC) and Forced Expiratory
Volume in 1 second (FEV1) and a statistically significant increase in irritated throat symptoms. In actors with mineral oil exposure greater than two times the Broadway average, significant decreases were found in FVC only. There were no significant abnormalities in lung function tests associated with exposure to glycols or pyrotechnics.
However, for most actors there was mild but not clinically or statistically significant decreases in lung function after a performance compared with before which was associated with exposure to any type of theatrical effect.
16 Study #4: Exposure and Health Effects from Exposure to Propylene Glycol Mist in
Aviation Emergency Training
A controlled human exposure inhalation study to propylene glycol mist (a type of glycol- based theatrical smoke) was conducted in the aviation industry as theatrical smoke is commonly used for emergency training (Weislander, Norback et al. 2001).
Methods
Non-asthmatic volunteers (n=27) were exposed to propylene glycol-based theatrical smoke for 1 minute during realistic training conditions over the course of a day. Medical investigation was conducted before and after exposure and included an estimate of tear film stability break up time, nasal patency by acoustic rhinometry, dynamic spirometry and a symptom's questionnaire.
Results
The geometric mean concentration of propylene glycol was 309 mg/m3 (range 176-
851mg/m ) over 1 minute. Average exposures in the morning were 220 mg/m compared to 520 mg/m in the afternoon. Tear film stability decreased, ocular and throat symptoms increased, FEV1/FVC was slightly reduced and self-related severity of dyspnea was slightly increased. Four subjects developed irritative cough and they had an average reduction in FEV1 of 5% compared with a 0% reduction among those who did not develop a cough. In the low exposure group, 47% reported development of throat dryness compared with 100% of subjects in the high exposure group.
17 3.2 Respiratory and Mucous Membrane effects from exposure to Glycols found in
Fog Fluid
Overall, exposure to glycol was found to cause irritation of the mucous membranes including the eyes, nose and throat. Findings for the specific glycols are listed below (see
Table 3.1 for Physical-Chemical properties for these glycols).
Dipropylene glycol
Dipropylene glycol is used as a solvent in perfumes and other cosmetics. No studies on the effects of inhalation of dipropylene glycol were found (HSDBd 2002).
Triethylene glycol
Triethylene glycol is used as a plasticizer, air disinfectant, as a solvent in textile dyeing and printing, and as a humectant in tobacco. It is considered to be an irritant of the eye.
Inhalation studies on monkeys and rats at the levels used in air disinfection (6.24 mg/m3) did not cause any physiological effect (HSDBa 2002).
Glycerol
An inhalation study of glycerol in rats exposed for 5 days/wk, 6 hours/day for 14 days to levels ranging from 1000-4000 mg/m3 found mild squamous metaplasia of epithelium lining the epiglottis (Renne, Wehner et al. 1992). Another part of the study looked at exposures for 5d/wk, 6h/d for 13 weeks to either 165mg/m3 or 660mg/m3 and found similar changes only in the group exposed to 660 mg/m3. A No Observed Effects Level
(NOAEL) of 167 mg/m3 was determined (Renne, Wehner et al. 1992).
18 Propylene glycol (1,2-Propanediol)
Propylene glycol is used as an intermediate in synthesis of organic compounds, including polypropylene glycol and polyester resins. It is a component of antifreeze mixtures, hydraulic fluids, brake fluid. It is used as a solvent in drugs, cosmetics and food products and as a humectant, bactericide (air sterilization), energy source in animal feed, vehicle for administration of drugs, and a plasticizer (CHEMFNFOa 1995).
As mentioned earlier, humans were exposed under controlled conditions to propylene glycol mist during aviation emergency training. It was found that tear film stability decreased, occular and throat symptoms increased, FEV1/FVC was slightly reduced, and self-rated dyspnea was slightly increased (Weislander, Norback et al. 2001). Another clinical inhalation study found that inhaled propylene glycol aided in sputum production
(Olsen, Froeb et al. 1961). Propylene glycol had been suspected of causing nasal burning, stinging and throat irritation in a nasal spray. A clinical study compared symptoms from 2 formulations of the nasal spray with differing amounts of propylene glycol. It was found that the formulation containing a lower amount of propylene glycol was found to cause less nasal burning, stinging and throat irritation when compared to the formulation which had a higher amount (Greenbaum, Leznoff et al. 1988).
Animal inhalation studies were also conducted on propylene glycol. A study of nose- only inhalation in rats for a duration of 5 days/week, 6hours/day for 13 weeks at a level of 100, 1000 or 2200 mg/m3 found no differences in respiratory rates, minute volumes or tidal volumes between treatment groups. However, an increase in the number of goblet
19 cells or in musin content of existing goblet cells in the nasal passages of medium and high exposure animals was found. Nasal hemorrage and occular discharge was noted in a high proportion of animals and was believed to be caused by dehydration of nares and eyes (Suber, Deskin et al. 1989).
1,3-butylene glycol (1,3-butanediol)
Widespread use of 1,3-butylene glycol is found in cosmetics and medicaments.
Inhalation studies on 1,3-butanediol were not found for humans or animals. A small amount of 1,3-butanediol applied to the eye causes immediate stinging in humans
(HSDBb 2002).
Polyethylene glycol 200
Polyethylene glycol 200 is a fraction of glycols with an average molecular weight of 200.
It exists in a liquid state at room temperature. Inhalation studies on polyethylene glycol were not found. In humans, when applied to the eyes in a 1:1 solution with water, a slight burning sensation was reported but no injury resulted: a 1:2 solution caused no irritation. In feeding studies on dogs, at levels of 2% of diet for 1 year, no adverse effects were found. In rats, no adverse effects were found when fed for 2 years at a level of 2% of diet (HSDBc 2002).
20 3.3 Allergic Contact Sensitization related to Glycols
Correlations have been found between protein reactivity of chemicals and the potential to cause skin sensitization. The potential of a chemical to cause contact allergy is also modulated by its ability in penetrating the skin. Some glycols are commonly used as a vehicle in medications in order to pass through the skin. In studies that attempted to sensitize individuals to a particular chemical, it was found that increasing the dose and repeated doses lead to an increased number of individuals having allergic sensitization to the chemical (Kimber and Maurer 1996).
Many of the glycols found to cause allergic sensitization are also found in cosmetics.
Dermal contact with chemicals has also been found to cause respiratory sensitization to that chemical (Kimber 1996). Since performers often wear makeup on stage and makeup technicians can be on the set and exposed to smoke, the potential for dermal sensitization may be most important to these job groups.
A limited number of studies of allergic contact dermatitis related to various glycol exposures were found for the glycols used in theatrical smokes. Studies linking allergic contact dermatitis to exposure to glycols were found for all glycols used in theatrical smoke except for triethylene glycol. Case studies and skin patch testing have linked allergic sensitization from exposure to polyethylene glycol, dipropylene glycol, 1,3- butylene glycol, propylene glycol and glycerol (Maibach 1975; Hannuksela and Forstrom
1976; Fisher 1977; Hannuksela and Forstrom 1978; Angelini, Vena et al. 1985; Bajaj,
21 Gupta et al. 1990; Catanzaro and Smith 1991; Johansen, Jemec et al. 1995; Sugiura and
Hayakawa 1997; Diegenant, Constandt et al. 2000). It has also been found that oral exposure to propylene glycol can cause skin rashes in sensitized individuals (Hannuksela and Forstrom 1978).
Dipropylene Glycol
One study looked at 503 eczema patients (212 men, 291 women) and conducted patch testing to assess the potential for contact dermatitis from dermal exposure to dipropylene glycol; allergic reactions in 6.7% of the study population were found (Johansen, Jemec et al. 1995).
Glycerol
One case of allergic contact sensitization to glycerol was reported which was confirmed with skin testing (Hannuksela and Forstrom 1976).
Propylene glycol
Studies conducted on allergic contact dermatitis from propylene glycol have reported frequencies of 0.2-12.5% in study populations (Catanzaro and Smith 1991). A study which used the criteria of repeated positive patch tests, positive oral exposure tests and positive usage tests found a rate of 0.8% out of 3364 patients with eczema (Angelini,
Vena et al. 1985). Another study using a group of 38 patients with allergic type reactions to propylene glycol and 20 control patients found that in the allergic group only, 15
22 patients developed a rash 3-16 hours after ingestion of a mixture with 2% or 6% propylene glycol (Hannuksela and Forstrom 1978).
1,3-butylene glycol
In a study testing 364 patients believed to have cosmetics-related contact dermatitis, 4 positive reactions to 1,3-butylene glycol (1.1% of study population) were found (Sugiura and Hayakawa 1997). Another study with 272 patients found a frequency of allergic reactions of 0.4%. While this compound is considered a rare contact allergen, it is believed that more frequent reports of allergy would result should it be tested regularly
(Diegenant, Constandt et al. 2000).
Polyethylene glycol 200
Low molecular weight polyethylene glycols (MW 200-400) including polyethylene glycol 200 have been found to cause contact urticaria and delayed eczematous reactions
(Maibach 1975; Fisher 1977; Bajaj, Gupta et al. 1990). Frequencies of allergic reactions to polyethylene glycols in study populations ranged from 0.5% to 4.4% (Maibach 1975;
Bajaj, Gupta et al. 1990).
23 9
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c o 'o 00 CD •3 55 co CL .CD %3 OT c OT o -Q £.8 CD E !:si E .8 1 ii a. i2 2? o 0 g. CO o 2: O LL *= o C/3 LL o > CQ 3.4 Respiratory Health Effects from Inhalation Exposure to Mineral Oil
White Mineral Oil
CAS Registry Number 8012-95-1
Chemical Family: Mixed hydrocarbons/petroleum hydrocarbons
Molecular Formula: Complex hydrocarbon mixture
Boiling Point: 360 C
(CHEMINFOb 1995; HSDBe 2002)
In fog fluids consisting of mineral oils, highly refined mineral oils are used; they are also known as food grade mineral oils. No studies were found which looked at inhalation to food grade mineral oil. One study looked at an oil fog exposure in rats created by using light-weight lubricating oil which would not be a highly refined or food-grade mineral oil. The rats were exposed to 1500, 500, 200 or 0 mg/m3 of oil fog for 3.5h/d, 4d/wk for
13 wks. Diffuse accumulation of macrophages in alveoli were found in all oil exposure groups. In rats given a 4 week recovery period, lung weight alterations were still found at the highest exposure level. The authors concluded that the changes were consistent with mild inflammatory edema (Selgrade, Hatch et al. 1990). Mineral oil fogs are used by the
US military to mask troop movement and also in hiding ships. A review paper published by the US military found that respiratory effects such as lipoid granulomas and lipoid pneumonias are possible with exposures to mineral oil fogs.. These lipoid pneumonias may be asymptomatic or cause symptoms such as occasional to severe cough, loss of pulmonary function, severe debilitating dyspnea and pulmonary illness and may also lead to bacterial infections. It was reported that an exposure limit of 5mg/m3 for 8hr time-
25 weighted average would protect against these effects. Recommendations were made that toxicity studies should be conducted to obtain data on the effects of fog oil mist concentrations between 5-63 mg/m3 with mice, rats, and monkeys (Palmer 1990).
Some metal working fluids also consist of mineral oil. Exposure to mineral oil mists in occupational settings at mean concentrations of 2.6 mg/m3 (below the ACGIH threshold
limit value of 5 mg/m3) have been found to cause adverse chronic respiratory effects such
as chronic cough, chronic phlegm, decreases in forced expiratory volume in 1 second
(FEV1), maximal flow rate at 50% and 25% of exhaled forced vital capacity (FEF25-75)
(Ameille, Wild et al. 1995). Exposure to metal working fluids has also been linked to respiratory diseases such as hypersensitivity pneumonitis, occupational asthma, industrial bronchitis and pulmonary fibrosis (Skyberg, Ronneberg et al. 1992; Spickard and
Hirschmann 1994; Zacharisen, Kadambi et al. 1998). It is unclear how these studies may relate to exposure to food-grade mineral oil mists as metal working fluids contain many additives including emulsifiers, corrosion inhibitors, germicides, colorants, anti-foamers, perfumes, extreme pressure additives which may also be a cause or partial cause of respiratory outcomes (Ameille, Wild et al. 1995). Other contamination which may have effects on respiratory health include exposure to the metal that is cut and microbial contamination (Ameille, Wild et al. 1995).
3.5 Respiratory and Mucous Membrane Irritation from Aldehydes
As mentioned earlier, it is believed that pyrolysis products such as formaldehyde, acrolein, acetaldehyde could be formed from the overheating of glycol-based fog fluids.
26 All three compounds are well known upper respiratory tract irritants and especially irritate the nose with inhalation exposure. Separate exposure and combined exposure to all three is known to cause histopathological changes and cell proliferation of the nasal epithelium (Cassee, Groten et al. 1996).
Ambient formaldehyde mainly affects the upper airways and eyes. Irritation of the eyes can occur at levels between 0.1 to 2.0 ppm, irritation of the nose and throat are likely at levels between 1.0 and 11.0 ppm. Lower airway and pulmonary effects may occur at levels between 5 and 30 ppm (Bardana and Montanaro 1991).
27 4 Objectives
Specific health effects study objectives were as follows:
• To collect information about respiratory symptoms, mucous membrane irritation, skin irritation, nasal irritation, sputum production and pre/post-shift lung function among the staff whose exposures are measured which will include one member each from the cast, crew, makeup and special effects technicians
• To evaluate the association between theatrical smoke exposure levels and these health symptoms.
• To determine if certain fog fluids may be associated with less symptoms than others based on their chemical ingredients. For example, a comparison of health effects from glycol- and mineral oil-based fluids, and a comparison of health effects from differing glycol fog fluids.
• To determine if certain methods of producing fog may be associated with less symptoms than others. For example, the use of mechanical versus heat fog production methods.
• To assess the association between working as a makeup personnel and reporting of health symptoms from glycol-based theatrical smokes as they would also have additional dermal exposure to glycol from working with cosmetics which contain glycols.
• To assess the association between working as a costume personnel and reporting of health symptoms as costume personnel would be exposed to various cleaning fluids in addition to theatrical smoke
28 5 Methods
5.1 Selection of Study Sites
A structured in-person interview was conducted with special effects technicians (from a list obtained by International Photographers Guild IATSE 699) in order to determine the equipment and chemicals that they commonly use for creating theatrical smoke. During this interview, the technicians were asked if they would like to have their current or following production site participate in an aerosol exposure measurement study (21 of 23 special effects technicians had agreed). Despite, the willingness of technicians to allow the UBC team to be at the production set, difficulties arose as management was required to give permission for the team to be on set and access to other employees working on the set. Because of these new problems in obtaining study sites, and the likelihood of not obtaining enough study sites, it was not feasible to continue with random sampling and the protocol was changed to convenience sampling and changed from a focus only on television/film productions to including live theatre, live music, and other productions such as a video arcade. Where possible, each site would be sampled on more than 1 occasion.
In order to contact productions where smoke may be used, film and television production lists were obtained by the International Photographers Guild IATSE699 website
(http://www.ia669.com/productions.hti-nl updated weekly) and from the BC film commission website (http://www.bcfilmcommission.ca updated weekly)
29 For every production, the production manager and producer were sent an information package which included a summary explanation of the study, methodology of aerosol exposure monitoring, employee health monitoring and asked for participation. Letters of support were obtained from the Director's Guild of Canada, IATSE 891, Canadian Film and Television Production Association, Alliance of Motion Picture and Television
Producers and the Vancouver Musician's Association. Telephone follow-ups were made
1 week later and in the event that contact could not be made, personal visits to specific production offices were made in order to encourage participation in the study. Lists of concert promoters were obtained by contacting concert venues and speaking with the technical director. Live theatre venues were contacted in the same manner. The concert promoters and technical directors were contacted in a similar manner as with the production manager. Entertainment trade newspapers were checked weekly in order to contact new theatre productions and concert productions where smoke may be used.
Once a site/production agreed to participate in the study, up to 5 individuals on site on the test day were invited to participate in the health and exposure monitoring survey. Three strategies were used in recruiting participants; the goal with each strategy was to obtain at least one participant from both hair/makeup departments and special effects. Initially, the production manager at the site was asked to provide 5 participants for the study. The second strategy involved the aid of a production assistant; SHAPE had offered to pay for the services of a production assistant for each sampling day with the agreement that the assistant recruited subjects for the study. Thirdly, in the event that participants were not found by the previous 2 methods, the UBC team would show up at the time that workers
were arriving on set (normally '/2 to 1 hour before the start of work). Workers were
30 approached during breakfast and on set if needed. Because lung function testing and completion of the acute questionnaire took approximately 10 minutes to complete for each subject (totaling 50 minutes for 5 subjects) and needed to be completed before the use of smoke on set, most times there was only 5-10 minutes in which to obtain subjects in order to complete pre-testing before the use of smoke. The majority of site visits involved the third strategy of recruitment by the UBC team and due to the time constraints previously mentioned, the team was required to move quickly around the set asking as many people as possible until 5 workers were identified or time ran out for testing 5 workers. In the majority of the cases, the noise and size of the personal sampling pumps were the main reasons for refusal.
5.2 Exposure Monitoring
Exposure monitoring and analysis was conducted by another Industrial Hygienist working on the project. The methods are being described here for completeness as the exposure data was used in some analyses for this thesis.
5.2.1 Area Exposure Measurements
On each sampling day, one location within the area that smokes and fogs were used was selected for area monitoring using a 7-hole inhalable aerosol sampler with a sorbent tube attached and a Marple 290 Personal Cascade Impactor mounted with 34mm 5 micron pore size polyvinyl chloride (PVC) filters at a calibrated flow rate of 2.0L/min+/- 5% with portable constant-flow sampling pumps (SKC, Eighty-Four, PA, USA). The Marple impactor allows size-fractionation into 5 fractions between 21 and 3.5 um and allows
31 calculation of the inhalable, thoracic, and respirable particulate masses. Two other sorbent tubes silica gel tubes (SKC) and XAD-7 (SKQOVS) tubes calibrated at
1.0L/min+/-5% and 2.0L/min+/-5% were used in evaluating the air concentrations of aldehydes and glycols, respectively.
Field Blanks and Detection Limits
One field blank was collected for each filter type and sorbent tube for every site. The average concentration detection limits for the Teflon filters and PVC filters based on 4 hrs of sampling at 2.0 L/mm was 0.022 mg/m and 0.042 mg/m , respectively.
Sample Analysis
All of the filter air samples were quantified gravimetrically on a micro-balance
(Sartorius, M3P, Germany) at the School of Occupational and Environmental Hygiene laboratory. Before triplicate pre-sampling weighing, filters were equilibrated for at least
24 hours to a stable temperature and relative humidity (22C +/-0.3C and 45% +/- 5% relative humidity). Before triplicate post-sampling weighing, the filters were desiccated for 24 hours and then equilibrated for at least 24 hours to a stable temperature and relative humidity (22C +/-0.3C and 45%+/-5% relative humidity).
The PAH, aldehyde and glycol sorbent tubes were analyzed at the School of
Occupational and Environmental Hygiene laboratory using gas chromatography flame ionization detector (NIOSH Method 5515; toluene for solvent extraction), high performance liquid chromatography (WCB Method 5270), and gas chromatography mass spectrometry (Revised NIOSH Method 5523; gas chromatography mass spectrometry
32 instead of gas chromatography flame ionization detector, ethanol instead of methanol for desorption solvent and Supelco SPB-100 column instead of Rtx-35 fused silica capillary), respectively.
Samples of the liquid mixtures (fog fluids) that were used in generating the smoke effects along with their accompanying Material Safety Data Sheets were collected from each location. These samples were also analyzed at the School of Occupational and
Environmental Hygiene laboratory by gas chromatography-mass spectrometry (Supelco
SPB-1000) to verify their constituents according to the Material Safety Data Sheets.
5.2.2 Personal Exposure Measurements
On each monitoring day, up to 5 individuals were asked to wear personal samplers; where possible, one member of the special effects crew and one member of the hair and makeup crew were asked to be included among the 5 participants. The reasons for exposure monitoring were explained to the subjects who were then asked to sign a consent form (see Appendix A). Each participant was fitted with a 7-hole inhalable aerosol sampler (JS Holdings Ltd., Stevanage, UK) mounted with a 25mm diameter 0.45 pore-size Teflon filter (Gelman Sciences, Ann Arbor, MI, USA) prior to generation of smokes. A sorbent tube (Supelpak 20U Orbo43) was added to the sampling train, placed between the filter and pump, to test the air for polycyclic aromatic hydrocarbons. Air was drawn through the filters with portable constant-flow sampling pumps (SKC, Eighty-
Four, PA, USA) at a flow rate of 2.0 L/min+/-5%. The pumps were calibrated before and after sampling using a calibrated rotameter (Matheson Tri-Gas, Montgomery, PA, USA).
A calibration curve for the rotameter was established at the University of British
33 Columbia School of Occupational and Environmental Hygiene laboratory using an automated soap-film flow meter (Gillibrator, Gilian, USA) as the primary standard. The duration of sampling was at least 4 hours (or the duration of the production for those less than 4 hours), which included a period where visible smoke was present.
For the duration of the sampling period, factors that may have been associated with levels of exposure were recorded. For personal sampling, work tasks performed by the subjects were recorded every 10 minutes using the following task categories: 1. refilling fluids/maintenance on fog machine; 2. operating fog machine; 3. working within 10 ft of fog machine while 'ON'; 4. working inside stage/studio within 20 ft from main production set; and 6. outside smoke/fog area (outside studio/stage). The distance that the subject was away from the primary smoke/fog machine, the distance that the subject was away from the primary/active set, and whether visible smoke/fog effect is present around the subject were collected simultaneously for the task performed every 10 minutes. Further to this, the job title of staff wearing a personal sampling device, the number of people similarly exposed (same job title), and the use of personal protective equipment was recorded. For area sampling, the following factors were recorded: 1. temperature, relative humidity, and atmospheric pressure; 2. location of area samplers (distance away from primary smoke/fog machine); 3. Stage dimensions (length, width, and height); 4. type of production; 5. indoor or outdoor production; 6. number of smoke/fog fluid used for each machine; 7. manufacturer and model of each smoke/fog machine; 8. type of smoke/fog fluid used for each machine; and 9. visual effect created with each machine (source
34 smoke, large volume smoke, smoldering effect, atmospheric/haze, low lying fog, coloured smoke, and steam).
5.3 Health Effects
5.3.1 Participation, study design
A pilot survey of potential health effects of exposure to theatrical smokes was conducted on the same individuals who participated in the exposure monitoring survey. Each individual who participated in the exposure monitoring was invited to participate in the health effects component of the study.
The general design of the health study involved pre-shift and post-shift evaluation of symptoms and pulmonary function. The pre-shift period was expected to be conducted prior to any significant exposure to theatrical smoke on the test day. The 'shift' period was expected to involve a minimum of 4 hours work (except situations where productions lasted less than 4 hours), during which theatrical smoke would be present at the site for at least some definable period of time.
5.3.2 Ethics, informed consent
Before conducting the health survey, each participant was informed that he or she may decline to participate or may stop participation at any time without prejudice. The procedures were explained in detail (orally and with a written consent form) and signed consent forms (Appendix A) were obtained from each individual.
35 With the approval of the human subjects, personal results remain stored securely and confidentially in the research team's offices and will be released only with the written consent of the individual.
5.3.3 Questionnaires
Two standardized questionnaires were administered to each participant by a trained interviewer: one focusing on general health status, 'chronic' or ongoing symptoms
(referred to here as the "General Health Questionnaire' and the other focusing on symptoms experienced on the testing day (referred to here as the 'Acute Symptoms
Questionnaire').
General Health Questionnaire:
An expanded version of the American Thoracic Society standard questionnaire recommended for use in epidemiologic surveys was used (Ferris 1978). Additional questions from the European Respiratory Health Survey standardized questionnaire for asthma were included (Burney, Luczynska et al. 1994) as were questions regarding mucous membrane irritation, skin and voice symptoms adapted from the Voice Handicap
Index (a standard questionnaire used in speech pathology for evaluating voice problems)
(Jacobsen, Johnson et al. 1997). Symptoms were only reported as being present if the participant provided an unequivocal 'yes' response. Any uncertainty or hesitation in response to questions regarding these symptoms was treated as a negative response. The questionnaire was similar to that used by our research team for previous studies at worksites throughout British Columbia, with additional questions on voice and skin symptoms which were believed to be important to this study.
36 Also included were questions to evaluate demographic and other health and exposure factors that may influence symptoms (e.g., age, history of asthma, cigarette smoking, history of other irritant or allergenic exposures, and a detailed past and current employment history).
Acute Symptoms Questionnaire
A brief questionnaire was also completed by each participant before and after the exposure monitoring period. This questionnaire was similar to the one used by our research team in a recent study of acute and chronic symptoms in the lumber industry.
The questionnaire includes a list of upper and lower respiratory, eye, mucous membrane, and systemic symptoms (including some not expected to be influenced by the exposures present). The participants were asked to identify if the symptom was present in the past 8 hours (pre-exposure questionnaire) or during the exposure period (post-exposure questionnaire), and if so, to choose from statements regarding severity.
Sample questionnaires are included in Appendix A
5.3.4 Physiologic testing
Physiologic testing of pulmonary function testing was carried out by a trained technician, before and after the exposure monitoring period, using a volume sensitive dry rolling seal spirometer (S&M Instruments, Doylestown PA), following American Thoracic Society standard procedures (American Thoracic Society 1995). Subjects were tested while they were seated and wearing nose-clips. A minimum of 3 acceptable forced vital capacity maneuvers were obtained on each occasion. According to this criteria a spirogram was deemed acceptable if there was: no cough or glottis closure during the first second of
37 exhalation; no early termination or cutoff; no variable effort; no leak; no obstructed mouthpiece; a good start; a plateau in the volume-time curve or the subject could not or should not continue to exhale. For reproducibility, the 2 largest FVC and FEV1 must be within 0.2 L of each other.
To allow us to control for the atopic (or 'allergic') status of the study subjects, allergy skin testing was conducted using three common environmental antigens (mixed Pacific grasses, cat epidermal antigen, house dust mite) and both positive (histamine 2.5 mg/ml) and negative (normal saline) controls. Atopy was defined as having one or more positive test. A test was positive if the mean wheal diameter was 3 mm or more greater than that of the negative control. For subjects who refused to take part in allergy skin testing, atopic status was considered to be positive for subjects reporting ever having hay fever.
5.3.5 Comparison data
Data used for comparisons of chronic respiratory symptoms came from a previous study carried out by the School of Occupational and Environmental Hygiene at UBC. This study was conducted on employees of the BC Ferries Corporation who worked on the ships because there was concern among employees about exposure to asbestos. A similar questionnaire and the same spirometry equipment were used in this study. It was found that only a subgroup of employees (maintenance and engine room crew) suffered effects from previous exposure to asbestos and these employees were left out of the comparison group. The employees that remained in the group (deck crew, kitchen staff, and stewards) were not exposed to asbestos but may have had occupational exposures to
38 respiratory irritants such as vehicle exhaust, kitchen smoke, cleaning and disinfecting chemicals. As the employees were much older on average than the entertainment industry group, age matching was carried out to create an ideal subgroup of workers.
Despite this, the control group still was slightly older on average, so age was controlled for in comparisons with the entertainment industry group. The workers that were left formed a suitable control group with prevalence rates of respiratory symptoms for employees who were concerned about exposure to a respiratory hazard but were not likely to be affected.
5.3.6 Data management and analysis
Questionnaires were coded and data was entered into computer files by double entry keypunching. Coding and computer files were checked for accuracy and consistency prior to analysis.
39 The health outcome variables analyzed were as follows:
General (or 'chronic') symptoms:
Variable Name Explanation of Variable any cough Subject reported yes to any of the following questions: Do you usually have a cough?/Do you usually cough at all on getting up or first thing in the morning?/Do you usually cough at all during the rest of the day or night? work-related cough Subject was positive for any cough and reported: improvement of cough on days off AND/OR long holidays AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making the cough worse. (If cough started before the age of 16 then subject was considered not to have work-related cough.) any phlegm Subject reported yes to any of the following questions: Do you usually bring up phlegm from your chest (exclude phlegm with first smoke or fist going out of doors. Count swallowed phlegm. Exclude phlegm from the nose)?/Do you usually bring up phlegm at all on getting up or first thing in the morning/Do you usually bring up phlegm at all during the rest of the day or night. work-related phlegm Subject was positive for any phlegm and reported: improvement of phlegm on days off AND/OR long holidays AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making them bring up phlegm. (If phlegm symptom started before the age of 16 then worker was considered not to have work-related phlegm.) work-related wheeze Subject reported: chest sounding wheezy or whistling occasionally apart from colds or most days and nights AND wheeze improving on days off and/or long holidays AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making them wheeze or wheeze worse. (Subjects who had wheeze starting before the age of 16 were considered not to have work-related wheeze).
40 work-related chest Subject reported: episodes of chest tightness which was tightness associated in difficulty in breathing AND the episodes improving on days off AND/OR long holidays AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making the chest tightness worse. (Subjects who had chest tightness starting before the age of 16 were considered not to have work-related chest- tightness.) work-related eye Subject reported: usually having burning, itching, watering symptoms eyes AND improvement on days off AND/OR long holidays AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making the symptoms worse. (Subjects who had eye symptoms starting before the age of 16 were considered not to have work-related eye symptoms.) work-related sneezing Subject reported: ever having sneezing or an itchy runny nose when they did not have a cold AND improvement on days off AND/OR long holidays AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making the symptoms worse. (Subjects with sneezing symptoms starting before the age of 16 were not considered to have work-related sneezing.) work-related stuffy or Subject reported: usually having a stuffy or blocked nose blocked nose AND improvement on days off AND/OR long holidays AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making the symptoms worse. (Subjects with symptoms starting before the age of 16 were not considered to have work-related stuffy or blocked nose.) work-related nasal If subject had work-related sneezing AND/OR work-related symptoms stuffy or blocked nose AND/OR reported work-related situations or environments (i.e. general work-related environments, mask/respirator, dust, humidity, engine fumes, smokes and fogs) making the nasal symptoms worse. work-related voice If subject reported: usually having problems with their voice symptoms AND improvement on days off AND/OR long holidays. (Subjects with voice problems starting before the age of 16 were not considered to have work-related voice symptoms.)
41 work-related skin rashes If subject reported: often having skin rashes AND improvement on days off AND/OR long holidays. (Subjects with symptoms starting before the age of 16 were not considered to have work-related skin rashes.) adult-onset eczema If the subject reported: currently having eczema with onset after 16 years of age. adult-onset asthma If subject reported: currently having asthma and onset followed work in entertainment industry.
For these symptoms, 'work-related' means the symptom improves on holidays or extended periods off work, or is aggravated by exposures at work, and it has only been present since age of 16.
Baseline lung function
Baseline (or 'pre-exposure') lung function status was determined using the 'pre-shift' values from the pulmonary testing. Following standard procedures, the maximum values for FVC (forced vital capacity), and FEV1 (forced expired volume in the first second) were used to choose the best effort. For some analyses, results are expressed as a percentage of predicted values (based on age, height, gender, and race) for healthy non- smokers (Crapo, Morris et al. 1981).
Acute symptoms
For the acute questionnaire subjects were asked both before exposure to smoke and approximately 4 hours later if they had: irritated eyes, red eyes, watery eyes, itchy eyes, runny/stuffy nose, nose bleeding, congestion, sneezing, sinus problems, sore throat, irritated throat, dry throat, dry cough, cough with phlegm, chest tightness, wheezing, breathlessness, nausea, stomach aches, drowsiness, dizziness, headache, tiredness, fever,
42 skin irritation, voice problems, joint pains, any other symptoms (in this case, subject was asked to specify).
Additionally, related symptoms were grouped according to their effects on specific symptoms in the body as follows.
Variable Name Explanation of Variable any 2 acute nose, throat, Any 2 symptoms reported out of the following group: runny or voice symptoms stuffy nose, nosebleeding, congestion, sneezing, sinus problems, sore throat, irritated throat, dry throat, voice problems acute cough Subject reported either dry cough or cough with phlegm acute chest symptoms Subject reported any of the following: dry cough, cough with phlegm, chest tightness, wheezing, breathlessness any acute dryness Subject reported dry cough AND/OR dry throat symptoms acute central nervous Subject reported any of the following: drowsiness, dizziness, system symptoms headache, tiredness acute eye symptoms Subject reported any of the following: irritated eyes, red eyes, watery eyes, itchy eyes
For these symptoms, an acute symptom is defined as being present if it was reported on the post-shift questionnaire, but not reported on the pre-shift questionnaire; or it was reported as increased in severity post-shift compared to the pre-shift questionnaire.
Acute changes in pulmonary function
The percentage change in FEV1 and FVC over the 'shift' was calculated as:
100 x ((post-shift value) - (pre-shift value)) / (pre-shift value)
43 Modifying factors taken into account (non-work factors)
Potential non-work factors taken into account in all analyses included age, current and past smoking habits (status and amount smoked), history of childhood asthma, atopic status (based on skin tests for common environmental antigens), height, race, and sex.
Work factors considered in analyses
The work 'exposure' variables examined in analyses included: Chronic Exposure Variables Variable Name Explanation of Variable Total # of days worked Participants reported sum of total # of days worked, for each job over the past 2 years % of days exposed to Of the total # of days worked, participants reported the smoke percentage of those days that they worked on productions where they were exposed to smoke, for each job over the past 2 years. Average hours/day On the days that smoke was used, participants reported the exposed to smoke average hours/day that they were exposed to smoke, for each job over the past 2 years. Usual Location on Set 1. working 10ft or less from smoke/fog machine 2. working inside studio/stage within 20ft of production set but not within 1 Oft of smoke machine 3. working inside studio/stage, but more than 20ft from production set • . 4. outside production set Location 1. mostly indoors 2. mostly outdoors 3. both, about the same Exposure duration (1—>n)Lx](Total # days worked * % of days exposed to smoke (Hours exposed to * average hours/day exposed to smoke of the smoke smoke over the past 2 days)/1000 years/1000) Units (Hrs/2yrs*1000) For all jobs over the past n=number of jobs over the past 2 years 2 years
44 Cumulative Exposure (l->n)0[(Total # days worked * % of days exposed to smoke (Intensity weighted * average hours/day exposed to smoke of the smoke hours exposed to smoke days)*weighting factor1 ]/l 000 over the past 2 Units (Hrs*(mg/m3)/2years*1000) years/1000) n=number of jobs over the past 2 years For all jobs over the past 1 the weighting factor was based on exposure assessment 2 years modeling data (not a part of this thesis) and was related to usual location on set and the following values were used 1.5 mg/m3:working 10ft or less from the smoke/fog machine 0.4 mg/m3:working inside studio/stage within 20ft of production set but not within 1 Oft of smoke machine 0.08 mg/m3:working inside studio/stage but more than 20ft from the production set or working outside the production set INDOORS 1= Sum of days worked indoors was greater than sum of days worked outdoors for all jobs over the past 2 years 0= Sum of days worked indoors for all jobs years was less than sum of days worked outdoors for all jobs over the past 2 years Current Days/Week Number of days/week worked on average in current Work production Unit: (days/week)
Current Hours/Day Number of hours/day worked on average in current production Unit: (hours/day)
Acute Exposure Variable Listing Variable Name Explanation of Variable Personal aerosol Personal 7-hole sampler inhalable aerosol concentration concentration (mg/m3) Personal Exposure on Sampling day Technician-reported Technician-reported minutes that subject spent in fog/30 Adjusted Minutes Spent Unit: (minutes/30) in Theatrical Smoke Subject-reported Self-reported minutes that subject spent in fog/30 Adjusted Minutes Spent Unit: (minutes/30) in Theatrical Smoke Glycol-based theatrical 1= Glycol-based fog fluid used on sampling day smoke 0= Non-glycol-based fog fluid used on sampling day Mineral Oil Based 1= Mineral Oil-based fog fluid used on sampling day theatrical smoke 0= Non-mineral oil-based fog fluid used on sampling day Acrolein detected Acrolein detected on sampling day in area samples 1: acrolein detected 0: 45 Percentage Respirable % of particles <3.5 um for area samples Fraction Percentage Thoracic % of particles 3.5-10 um for area samples Fraction Percentage Inhalable % of particles >10 um for area samples Fraction Statistical analyses Analyses were performed using SAS V8.01 statistical analysis software (SAS Institute Inc, Cary NC). Demographic characteristics and prevalence rates for chronic and 'work-related' symptoms and mean values for lung function parameters were compared to values from the comparison population. To examine work and other factors associated with the various health outcomes, regression analyses were carried out. These progressed from simple univariate analyses, through to multi-variable modeling, employing generalized linear models for continuous outcomes (lung function values, acute change in lung function) and logistic regression for dichotomous outcomes (acute and chronic symptoms). Prior to regression modeling, correlations among all potential predictor variables were examined. Where predictor variables were highly correlated choices were made as to which one to include in the model, based on a priori expectations. See Appendix B for tables explaining highly correlated variables and decisions made on variables used in the models. 46 Table 5-1 Description of Multivariable Models Type of Regression Used Description of Models* Logistic Regression (13 models in total) Chronic Symptoms: work-related (cough, phlegm, wheezing, chest tightness, nasal, skin rashes), Adult Onset Eczema Acute Symptoms: Any cough, Chest, 2 or more nose/throat/voice, dryness, CNS, any eye Linear Regression (5 models in total) Baseline Lung Function (FVC, FEV1, FEV1/FVC), % Cross Shift Lung Function Change (FVC, FEV1) * italics indicates outcome variable used for a specific model Multivariable Modeling for Chronic Symptoms Variables were added to the model according to biological plausibility related to the symptoms of concern in two steps. Firstly, in each model, personal factors were included in each model. Secondly, exposure variables related to chronic exposure (cumulative exposure or exposure duration) were added to the models. For chronic respiratory symptoms, the following personal factor variables were included in each model: age, sex, current smoker packyears, ex-smoker packyears, and atopic status. Current smoker packyears and ex-smoker packyears were selected over current and ex-smoker smoking status as they were believed to be more biologically relevant for symptoms as packyears is an indicator of cumulative dose for cigarette smoking. In addition to these variables, either of the computed chronic smoke exposure variables: cumulative exposure or duration of exposure were added to the models. Models for work-related skin rashes and work-related eczema differed from the chronic respiratory symptom models in that smoking status was not deemed biologically relevant 47 to skin rashes and eczema which left age, sex, and atopic status as the personal factor variables. For the second step, again exposure variables related to chronic exposure were added to these models. Multivariable Modeling for Acute Symptoms For acute symptoms, age, sex, childhood asthma, atopic status, and the number of cigarettes smoked during the sampling period were included as personal factors. The technician reported minutes spent in fog, personal aerosol concentration and an indicator variable to identify whether or not the production used Glycol- or Mineral Oil-based theatrical fog were included as exposure variables to models. Variables for formaldehyde concentration and detection of acrolein were tried in all acute symptom models (as it was believed that these could be breakdown products from the creation of glycol-based theatrical smoke and are known respiratory irritants). However, neither of these variables were significant in any of the models. Additionally, the percentage thoracic fraction was tried in the models of: any acute cough, acute chest symptoms and any acute dryness symptoms but were not significant. For the models of any 2 acute nose/throat/voice symptoms and acute dryness symptoms: inhalable and thoracic percentage fraction were each tried in the models (these fractions target the areas of the respiratory system of concern with regards to these symptoms) but again were not significant. For acute CNS symptoms, percentage respirable fraction was tried in models 48 (as this fraction is believed to be small enough to pass through the respiratory system and possibly cause systemic effects) but was not significant. Multivariable Modeling for Chronic Lung Function For baseline lung function results, (which were looking at the role of chronic exposure to theatrical smoke) age, sex, race, atopic status, childhood asthma, height, and smoking status were added as personal factors to the models. Additionally, for exposure variables, cumulative exposure or exposure duration were added to the models with the personal factors. Multivariable Modeling for Cross Shift Lung Function For cross-shift lung function models, (which looked at the effects of exposures on the sampling day) childhood asthma, atopic status, cigarettes smoked during sampling period were personal factors added to each model. In addition, a variable for duration of sampling time was added and a flag variable if post-shift lung function was conducted after 12pm. Normal circadian rhythms are a source of variability in lung function as lung function normally is lowest in early morning and tends to peak at noon (ATS 1991). This variability can have an effect on change in lung function found over the testing period. Exposure variables added to the models included technician reported minutes in fog, personal aerosol concentration, and an indicator variable to identify whether or not the production used either glycol- or mineral oil-based theatrical smoke. 49 Acrolein detected, formaldehyde concentration, percentage respirable fraction and thoracic fraction (as these fractions target the lower respiratory system) were tried separately in the FVC and FEV1 models but were not found to be significant. 50 6 Health Effects Study Results 6.1 Participation and Characteristics of Study Participants Table 6-1 Participation Subjects n(%) Total Eligible 144' Total Participated 111 (acute questionnaire, (77.1) lung function, personal monitoring) Total with Complete 101 Data (Skin prick tests (70.1) and chronic questionnaire) Including known Refusals The number of employees participating in the different phases of the study are included in Table 6.1. When production managers handled obtaining study subjects, refusal numbers were not collected so the total eligible number only includes known refusals. However, the majority of visits involved the UBC team obtaining study subjects. For television/film productions, music concerts and theatre, regular breaks were not allowed for employees to partake in the questionnaires and lung function testing which was required before the start of smoke for the day and approximately 4 hours later. There were 2 reasons given for refusal in study participation: obtrusiveness and/or noise of the personal sampling pumps, and participation interfering with the employees' ability to conduct their work. 'Acute' testing (lung function and acute symptoms questionnaire) was carried out at the worksite, but the "general" (chronic symptoms) questionnaire was usually completed outside of work. Many of the participants at music concerts and film productions worked 12 hrs/day on average with a maximum of 18hrs/day, and on average 4 days/week with a maximum of 6 days/week. Because of these demanding workweeks, 51 there was difficulty in scheduling the followup interviews outside of work as workers were less enthusiastic about arranging meetings during weekends or evenings after work. There were no known refusals for the second phase of followup interviews. However, there were 10 subjects who were not able to meet for a followup interview within a reasonable time after initial data collection. Table 6-2 Demographics Entertainment Comparison Group P Industry Group N 101 70 Age [mean (sd) 33.5 (10.2) 39.8 (8.7) <0.0001 Range] 18.5, 56.1 22.4, 55.9 Height (inch) 68.3 (3.5) 67.0 (3.9) 0.03 [mean (sd) 61.0, 76.0 59.1,76.0 range] Weight (lbs) 168.3 (35.5) 180.7 (42.9) 0.04 [mean (sd) 110.0, 270.0 121.3, 396.8 range] Female n(%) 33 (32.7%) 28 (40.0%) 0.3 Nonwhite n (%) 9 (8.9%) 7 (10.0%) 0.8 Smoking Status 0.6 Non n (%) 45 (44.6%) 26 (37.1%) Ex n (%) 24 (23.8%) 21 (30.0%) Current n (%) 32 (31.7%) 23 (32.9%) Packyears (Current 10.6(11.6) 15.2(12.0) 0.06 & Ex-smokers only) 0.1, 54.0 0.5, 44.0 [mean (sd) range] Current Smoker 3.5 (8.0) 5.8 (10.4) 0.1 Packyears (for all 0, 43.9 0, 39.5 categories) [mean (sd) range] Ex Smoker 2.4 (7.4) 3.5 (8.7) 0.4 Packyears (for all 0, 54.0 0, 44.0 categories) [mean (sd) range] 52 Table 6-3 Health History Entertainment Controls Group p* Industry Group n(%) n(%) n 101 70 Asthma Ever 17(16.8%) 10 (14.3%) 0.7 Current Asthma 10 (9.9%) 7 (10.0%) 1.0 Childhood Asthma 12(11.9%) 5 (7.1%) 0.3 MD diagnosed 14(13.9%) 7 (10.0%) 0.4 Adult Onset Asthma 2 (2.0%) 5 (7.1%) 0.2 Atopic (+skin test) 46 (45.5%) 28 (40.0%) 0.5 Heart disease 1 (1.0%) 0 (0%) 0.4 (treated in past 10 yrs) *chi square test The characteristics of study participants and summary characteristics of the comparison population are presented in Table 6.2 and 6.3. Despite attempts to age match, the comparison population from the BC Ferries study was, on average, older. There was a slightly larger percentage of ex-smokers among the comparison group. Packyears for current and ex-smokers was also higher on average in the comparison group as would be expected in an older population. Few differences were found between the groups for asthma or allergy skin test results. Asthma and atopy rates were slightly elevated in the entertainment industry but these results were not statistically significant. 6.2 Characteristics of Work Most subjects worked indoors on the current production where sampling took place as seen in Table 6.4 and the location that participants worked in relation to the smoke machine was roughly equally distributed between the first three categories: 1. working 10 ft or less from the smoke/fog machine; 2. working inside studio/stage; and 3. working inside studio/stage but more than 20ft from production set. As Table 6.5 shows, use of 53 respirators at work was quite low with 72% of subjects reporting never using a respirator and only, 2% reporting using a respirator all of the time or most of the time. One possible reason for low useage of respirators is that crew members were often required to wear headsets for communication on film/television sets and in music concerts and with the use of respirators, communication would become difficult. Based on personal communications with film production crews, it was reported that main actors would be less likely to be willing to work in smoke-filled environments should all crew members be fitted with respirators while they would be left to work without respiratory protection. Table 6-4 Set Location on Current Production n=101 Mostly Indoors 80 Mostly Outdoors 2 Both, about the same 19 Working 10ft or less from smoke/fog 36 machine Working inside studio/stage within 20ft 31 but not within 10ft of smoke machine Working inside studio/stage but more 31 than 20ft from production set Outside production set 3 Table 6-5 Respirator Useage at Work n=101 All of the 1 time Most of the 1 time Some of the 14 time Only rarely 13 Never 72 54 Table 6-6 Job Titles n=101 Standin 3 Makeup/Hair/Prosthetics 9 Special Effects 8 Technician Props Technician 3 Production Assistant 13 Cameraperson 3 Musician 1 Sound Technician 7 Production Manager 6 Grip 6 Stagehand 8 Lighting Technician 6 Assistant Director 4 Set Decorator 2 Playmaster 10 Computer/Video 2 Technician Costumes Technician 5 Trap Crew 4 Electronics Technician 1 As seen in Table 6.6, subjects' job titles were grouped into 19 categories. It was not possible to obtain participation from actors as the noise from pumps and their obtrusiveness would have interfered with their work. Work duration characteristics are provided in Table 6.7. A site was considered to be theatre if there was a play performed, a separate grouping was given for music concerts even though some concerts were performed in theatres. On average participants from live theatre worked more days per week than those in other production types. Participants from television/film and music concerts tended to work more hours per day at 13.0 and 12.5 hours respectively. Those working on concerts had the highest percentage of workdays being exposed to smoke at 55 90%, while on days where smoke was used, those working in television/film productions had the most hours per day exposed to smoke at 8.2 hours. Table 6-7 Work Duration Characteristics for Current Production All TV/Movie Theatre Concert Arcade p* Productions Mean Mean Mean Mean Mean (sd) (sd) (sd) (sd) (sd) range range range range range n 101 53 26 11 11 Total 49.5 34.9 23.9 37.3 192.5 <.0001 Number of (96.1) (28.7) (14.6) (120.3) (199.9) days worked 1, 600 1, 100 3, 60 1,400 25, 600 on current production Days 4.4 4.3 5.8 1.5 4.3 <.0001 worked/week (1.6) (1.2) (0-9) (1.5) (1.3) 1,7 1,5 4,7 1,6 2,6 Hours/day 10.4 13.0 5.5 12.5 7.5 <.0001 (3.9) (2.2) (1.8) (3.0) (0.7) 4, 18 6, 18 4, 10 8, 18 6, 8 % of days 71.1 66.4 74.8 90.1 65.5 0.09 exposed to (40.0) (30.2) (35.2) (20.2) (27.0) smoke 0, 100 0, 100 0, 100 50, 100 5, 100 Hours/day 5.6 8.2 1.6 3.8 4.3 <0001 exposed to (4-1) (3.8) (2.1) (1.2) (1.5) smoke 1, 15 0, 15 0, 10 1,5 2,8 * p value from ANOVA (continuous outcomes) As seen in Table 6.8, personal sampling revealed the highest personal aerosol concentrations were obtained from television/movie productions and were approximately twice as high on average than in other production types. The time spent in an environment where smoke was present for the sampling day was measured by both self- reported and technician-reported approaches that were highly correlated (Pearson's correlation coefficient 0.67). Although self-reported time was greater than technician- reported time, the order of time from highest to lowest remained the same for both 56 exposure variables and was as follows: arcade, concert, television/film, and theatre as revealed in Table 6.9. Table 6-8 Personal Exposure on Sampling Day All TV/Movie Theatre Concert Arcade p* Productions Mean Mean Mean Mean Mean (sd) (sd) (sd) (sd) (sd) range range range range range n 101 53 26 11 11 Personal 0.73 1.04 0.44 0.35 0.34 0.007 aerosol (0.96) (1.17) (0.60) (0.23) (0.13) concentration 0.02, 4.11 0.06, 4.11 0.02, 3.22 0.11,0.84 0.10,0.50 (mg/m3) * p-value from ANOVA (continuous outcomes) Table 6-9 Self-reported Exposure Variables for Sampling Day All TV/Movie Theatre Concert Arcade p* Productions mean mean mean mean mean (sd) (sd) (sd) (sd) (sd) range range range range range n 101 53 26 11 11 Self- 132.6 143.6 47.5 188.6 224.5 <.0001 reported (100.8) (87.2) (70.4) (124.7) (43.0) Minutes in 0, 390 0,390 0, 240 20, 360 120, 270 Fog on Sampling Day Technician- 86.0 93.8 33.5 119.0 140.0 <.0001 Reported (73.0) (74.9) (58.2) (47.2) (39.5) Minutes in 0, 250 0, 250 0, 240 70, 200 80, 200 Fog on Sampling Day p-value from ANOVA (continuous outcomes) 57 Table 6-10 Calculated Variables for Self-reported Past Smoke Exposure All TV/Movie Theatre Concert Arcade p* Productions mean mean mean mean mean (sd) (sd) (sd) (sd) (sd) range range range range range n 101 53 26 11 11 Exposure 0.97 1.53 0.16 0.69 0.50 <.0001 duration (Hours (1.20) (1.39) (0.22) (0.61) (0.47) exposed to 0, 6.48 0.02, 6.48 0, 0.61 0.06, 0.06, Smoke over the 2.04 1.65 Past 2 Years/1000) Cumulative 0.69 1.20 0.09 0.18 0.12 0.0001 Exposure to (1.25) (1.54) (0.17) (0.17) (0.19) Smoke over the 0, 6.08 0.01,6.08 0, 0.64 0.01, 0.01, Past 2 Years (in 0.48 0.66 mg/m3*hrs*1000) * p-value from ANOVA (continuous outcomes) Table 5.10 presented estimated chronic exposures over the past 2 years for 2 variables: exposure duration and cumulative exposure. Again, the pattern of exposure is the same in both exposure variables with the following order from highest to lowest exposure: television/film, music concert, arcade, and theatre. Intensity weighting is a measure of cumulative exposure and as mentioned in the methods section, weighting is based on proximity of work relative to the smoke/fog machine. This intensity weighting had the effect of narrowing the range of values. 58 6.3 Correlations among potential explanatory variables Results from analyses to examine correlations among demographic and "work or exposure" factors are included in Appendix B. Job titles of interest such as special effects technicians, makeup and costumes were left out of models. Special effects technicians had higher levels of cumulative exposure and exposure duration than the rest of the entertainment industry group. A significantly high proportion of makeup and costume personnel were female; makeup personnel also had higher levels of both cumulative exposure and exposure duration. Because of these associations between exposure and job titles and sex, it was decided to leave out these job titles in order to include exposure and sex into the models since the relationship between exposure and symptom was of primary importance and sex was considered a more important personal factor. Work predominantly indoors over the past 2 years was highly correlated with working on a television/film production (Pearson correlation coefficient -0.80). The average number of hours/day worked on the current production was highly correlated with work in theatre (Pearson correlation coefficient -0.73) and work in concerts (Pearson correlation coefficient -0.61). So it was decided that production type, work indoors and the hours/day worked on the current production would not be added to the models. 6.4 Respiratory Health Indicators-Entertainment Industry Group vs. Comparison Group Tables 6.11 and 6.12 show results of the analyses looking at health testing results for the entertainment industry group compared to the external comparison group. There were 59 higher prevalence rates of cough, phlegm, wheeze, chest tightness and shortness of breath (p<0.05 for shortness of breath only) among the entertainment industry employees compared to the control group. For work-related symptoms, a higher prevalence of wheeze was found and significantly higher rates of chest tightness, sneezing, and nasal symptoms were found among the entertainment industry population. Table 6-11 Chronic Symptoms Entertainment Control Group OR (95% CI) Industry Group * n(%) P n(%) n 101 70 Any Cough 19(18.8%) 7 (10.0%) 2.3 (0.8-6.7) 0.1 Any Phlegm 27 (26.7%) 14 (20.0%) 1.7(0.8-3.7) 0.2 Occasional Wheeze 31 (30.7%) 17 (24.3%) 1.9(0.9-4.0) 0.1 Any Chest tightness 23 (22.8%) 12(17.1%) 1.9(0.8-4.5) 0.1 Shortness of Breath 26 (25.7%) 10 (14.3%) 2.9(1.2-6.9) walking up hill 0.02 Work-related cough 6 (6.0%) 7 (10.0%) 0.4 (0.1-1.4) 0.2 Work-related 7 (7.0%) 4 (5.7%) 1.4 (0.4-5.5) phlegm 0.6 Work-related 8 (7.9%) 3 (4.3%) 2.5 (0.6-10.2) Wheeze 0.2 Work-related Chest 11 (10.9%) 1 (1.4%) 14.5 (1.7-121.3) Tightness 0.02 Work-related eye 3 (3.0%) 2 (2.9%) 1.1 (0.2-7.6) irritation 0.9 Work-related 40 (39.6%) 16 (22.9%) 3.0(1.4-6.5) Sneezing 0.004 Work-related Stuffy 13 (12.9%) 12(17.1%) 0.9 (0.4-2.3) Nose 0.9 Work-related Nasal 43 (42.6%) 21 (30.0%) 2.3 (1.1-4.6) Symptoms 0.03 Adult Onset Eczema 9 (8.9%) 7(10.0%) 1.3 (0.4-4.2) 0.6 * p-value after adjusting for differences in age, sex, smoking and atopy 60 Table 5.12 shows the pulmonary function test results. Two tests, FVC and FEV1 are presented. FEV1 is the volume of air exhaled in the first second and it is a measure of air flow. When reduced, it is an indication of obstruction of the airways. Reduced FEV1 is common in cigarette smokers and in response to respiratory irritants. FVC, a measure of lung volume, is the total volume exhaled. In restrictive diseases such as pulmonary fibrosis (or lung scarring) from exposure to substances such as asbestos, FVC and FEV1 would be reduced but the percent FEV1/FVC stays normal. With obstructive diseases, such as bronchial asthma, FEV1 is much more reduced than FVC which gives a low percentage FEV1/FVC. Both FEV1 and FVC were reduced on average with a 2.9% decrease in percent-predicted FEV1 and a 3.6% decrease on average in percent predicted FVC in the entertainment industry group (p<0.05 for FVC). The percent predicted values are adjusted for age, height, race and gender (Crapo, Morris et al. 1981). Table 6-12 Lung Function Results Smokes Group Controls Group P* mean (sd) mean (sd) range range % predicted FEV1 96.9(11.4) 99.8(15.4) 0.06 67.2, 127.2 35.4, 139.8 % predicted FVC 101.9(10.5) 105.5 (12.4) 0.03 80.0, 131.4 80.4, 140.9 * p-value after adjusting for differences in ex- and current-smoker packyears, and atopy 61 6.5 Respiratory Health Indicators in Relation to Theatrical Smoke Exposures: Entertainment Industry Group Only Tables 6.13 and 6.14 show the internal multivariable analysis for work-related symptoms and lung function respectively; each column represents all variables used in the model. Table 6.13 shows internal multivariable analysis for work-related symptoms in association with personal and work risk factors. Work-related cough and work-related phlegm were significantly associated with cumulative exposure. Table 6.14 shows results of the multivariable models for FEV1, FVC and percent FEV1/FVC. No significant associations were found between cumulative exposure and FEV1 or FVC. However, one unexpected finding was that cumulative exposure was significantly associated with an increase in percent FEV1/FVC. 62 Table 6-13 Odds Ratios for Multivariable Models for Reported Work-Related Respiratory Symptoms Cough Phlegm Wheezing Chest Nasal OR OR OR Tightness Symptoms (95%CI) (95%CI) (95%CI) OR OR (95%CI) (95%CI) Prevalence 6 7 8 11 43 n (%) (6.0%) (7%) (7.9%) (10.9%) (42.6%) Age 0.9 1.1 1.0 1.1 1.1 (0.8-1.0) (1.0-1.3) (0.9-1.1) (1.0-1.2) (1.0-1.1) Female 0.3 O.001 0.5 1.7 1.2 (0.03-4.0) (O.001- (0.1-3.1) (0.4-6.8) (0.5-2.9) >999.999) Current Smoker 1.1 1.0 1.0 1.0 1.0 Packyears (0.9-1.2) (0.9-1.2) (0.9-1.1) (0.9-1.1) (0.9-1.0) Ex-Smoker 0.8 0.5 1.1 1.0 1.0 Packyears (0.4-1.8) (0.01- (1.0-1.1) (1.0-1.1) (1.0-1.1) 15.8) Atopic Status 0.7 14.4 1.4 0.9 (0.2- 1.0 (0.1-5.5) (1.1- (0.3-6.3) 3.7) (0.4-2.4) 182.4) Cumulative 1.8 2.4 1.4 1.2 0.9 Exposure to (1.1-3.1) (1.1-5.3) (0.9-2.1) (0.8-1.9) (0.7-1.3) Smoke over the Past 2 Years (in mg/m3*hrs*1000) BOLD indicates p-value <0.05 63 Table 6-14 Linear Regression Multivariable Models for Lung Function Results FVC FEV1 FEV1/FVC B(se) P Intercept -4.61 -0.81 128.82 (1.46) (1.29) (18.32) 0.002 0.5 <.0001 Age -0.01 -0.03 -0.41 (0.01) (0.004) (0.06) 0.03 <.0001 <.0001 Female -0.67 -0.55 0.55 (0.15) (0.13) (1.86) <.0001 <0001 0.8 Nonwhite -0.49 -0.53 -2.36 (0-19) (0-17) (2.34) 0.01 0.002 0.3 Atopic Status -0.16 -0.08 0.35 (0.10) (0.09) (1.31) 0.1 0.4 0.8 Childhood Asthma 0.13 -0.14 -4.13 (0.17) (0.15) (2.10) 0.5 0.3 0.05 Height (inches) 0.15 0.09 -0.50 (0.02) (0.02) (0.26) <.0001 <.0001 0.06 Current Smoker 0.09 -0.21 -5.52 (0-12) (0.10) (1.49) 0.5 0.05 0.0004 Ex Smoker 0.08 -0.05 -2.08 (0.13) (0.12) (1.69) 0.6 0.7 0.2 Cumulative -0.02 0.04 1.17 Exposure to Smoke (0.04) (0.04) (0.52) over the Past 2 0.7 0.3 0.03 Years (in mg/m3*hrs*1000) 64 6.6 Dermal Health Indicators Results of the multivariable modeling for both work-related skin rashes and work-related eczema are presented in Table 6.15. Cumulative exposure was not significantly associated with work-related skin rashes or adult onset eczema. Table 6-15 Odds Ratio for Reported Skin Symptoms Work- Adult related Onset Skin Eczema Rashes Prevalence 5 (5.0%) 9 (8.9%) Age 1.0(0.9- 1.1 (1.0- 1.1) 1.1) Sex 0.5 (0.1- 1.7(0.4- 4.7) 7.2) Atopic Status 1.9(0.3- 0.7 (0.2- 12.3) 3.3) Cumulative Exposure to 1.2 (0.7- 1.3 (0.8- Smoke over the Past 2 2.1) 2.0) Years (in mg/m3*hrs*1000) 6.7 Acute Symptoms Incidence rates for acute symptoms and grouped acute symptoms are presented in Table 6.16 and Table 6.17. Dry throat (25.7%), irritated throat (13.9%), irritated eyes (10.9%), itchy eyes (10.9%) and tiredness (10.9%) were the 5 most frequently reported acute symptoms among the population. Among grouped symptoms, CNS (25.7%) and any dryness (30.7%) symptoms were the two highest reported grouped symptom categories. Table 6.17 shows results of the multivariable analysis of the grouped acute symptoms. 65 Females were significantly more likely (OR 4.7) to report 2 or more nose/throat or voice symptoms. Personal aerosol concentration was significantly associated with 2 or more nose/throat or voice symptoms. The use of glycol fog was significantly associated with dry throat/dry cough (OR 4.9), acute eye symptoms (OR 3.2), and CNS symptoms (OR 3.9). Table 6-16 Acute Symptoms Prevalence n=101 % Irritated eyes 11 10.9 Red eyes 1 1.0 Watery eyes 2 2.0 Itchy eyes 11 10.9 Runny stuffy nose 8 7.9 Nosebleeding 0 0 Sneezing 6 5.9 Sinus problems 3 3.0 Sore throat 6 5.9 Irritated throat 14 13.9 Dry throat 26 25.7 Dry cough 7 6.9 Cough with phlegm 2 2.0 Chest tightness 5 5.0 Wheezing 3 3.0 Breathlessness 2 2.0 Nausea 1 1.0 Stomach ache 1 1.0 Drowsiness 3 3.0 Dizziness 5 5.0 Headache 8 8.0 Tiredness 11 10.9 Fever 0 0 Skin irritation 2 2.0 Voice problems 3 3.0 Joint pain 4 4.0 Other symptoms 6 5.9 66 Table 6-17 Acute Symptoms by Grouping n % Acute Cough- 9 8.9 Acute Chest 16 15.8 Any 2 Acute 12 11.9 Nose/Throat/Voice Symptoms Any Acute Dryness 31 30.7 Acute Central Nervous 26 25.7 System Acute Eye 18 17.8 Table 6-18 Odds Ratios for Multivariable Models for Acute Symptoms Acute Acute Chest Any 2 Acute Any Acute Acute Eye Cough OR Nose/Throat/ Acute Central OR OR (95%CI) Voice Dryness Nervous (95%CI) (95%CI) OR (95%CI) OR System (95%CI) OR (95%CI) Prevalence 9 16 12 31 26 18 Age 0.9 (0.9- 1.0(1.0-1.1) 1.0(1.0-1.1) 1.0(1.0- 1.0(1.0- 1.0 (0.9- 1.0) 1.0) 1.0) 1.0) Female 0.6(0.1- 1.6(0.5-5.4) 4.7 (1.1-20.0) 2.1 (0.8- 1.1 (0.4- 1.8 (0.5- 3.5) 5.8) 3.3) 5.8) Childhood Asthma 1.6(0.3- 3.3 (0.7- 0.8(0.1-8.3) 0.6(0.1- 1.0(0.2- 0.7 (0.1- 10.1) 14.4) 2.6) 4.6) 4.1) Atopic Status 1.3 (0.3- 1.2 (0.4-3.9) 2.4 (0.5-10.6) 1.4 (0.5- 0.6 (0.2- 0.6 (0.2- 5.9) 3.6) 1.6) 2.0) Number of Cigarettes 1.3 (0.7- 1.3 (0.8-2.2) 1.1 (0.6-2.4) 1.5 (1.0- 1.0(0.6- 1.3 (0.8- Smoked during 2.4) 2.4) 1.6) 2.1) sampling period Technician-reported 1.0(0.7- 1.1 (0.9-1.5) 0.8 (0.6-1.2) 1.1 (0.9- 0.8 (0.6- 1.1 (0.8- Adjusted Minutes 1.5) 1.4) 1.1) 1.4) Spent in Theatrical Smoke Personal aerosol 0.6 (0.7- 0.8 (0.4-1.7) 2.2 (1.0-4.5) 0.9 (0.5- 1.6(0.9- 0.3 (0.1- concentration 1.5) 1.6) 2.9) 1.4) (mg/m3) Glycol-based 2.7 (0.5- 2.0 (0.6-6.7) 2.4 (0.5-9.7) 4.9 (1.7- 3.9 (1.4- 3.2 (1.0- theatrical smoke 14.2) 13.8) 11.3) 10.6) BOLD indicates p-value < 0.05 67 6.8 Cross-Shift Lung Function Results Table 6.19 shows results for percent cross-shift change in FEV1 and FVC. Personal aerosol concentration was not associated with the cross-shift change in either FEV1 or FVC. While glycol fog was associated with a significant positive effect on FEV1, when mineral oil was substituted in the model, a negative effect was noted which was near significance (p=0.1). Mineral oil was negatively associated with glycol fog (Pearson's correlation coefficient -0.85). Because of this strong negative association between mineral oil and glycol, it was not possible to determine whether glycol had a positive effect on lung function or whether mineral oil had a negative effect. When the models were stratified based on mineral oil or glycol, there was no significant association between FEV1 and technician reported time in fog or personal aerosol concentration in either model. 68 Table 6-19 Multivariable Cross-Shift Change in Lung Function % FVC Cross Shift % FEV1 Cross Shift Change Change B(se) B(se) P P Childhood Asthma -1.46 (1.32) -2.57(1.21) 0.3 0.04 Atopic Status 0.03 (0.83) 0.58 (0.76) 1.0 0.4 Cigarettes Smoked 0.12(0.38) -0.34 (0.34) during sampling 0.7 0.3 period Post-shift lung -0.85 (2.05) -1.23 (1.88) function test 0.7 0.5 conducted after 12pm Sampling Duration 0.0041 (0.0047) -0.0034 (0.0043) 0.4 0.4 Technician-reported -0.30(0.19) 0.09 (0.18) minutes in Fog/30 0.1 0.6 Personal aerosol 0.49 (0.48) 0.26 (0.44) concentration 0.3 0.6 (mg/m3) Glycol 0.44 (0.86) 1.84 (0.79) 0.6 0.02 Mineral Oil * -0.65 (0.87) -1.35 (0.81) 0.5 0.1 * mineral oil was substituted into the models for glycol with no significant changes to other variables 69 7 Discussion 7.1 Overview In summary, a higher prevalence for 9 of 10 chronic respiratory symptoms were found in the entertainment industry study population when compared to the comparison group; 4 of these symptoms with a higher prevalence were work-related respiratory symptoms. It is important to note that the comparison group consisted of a population concerned about exposure to asbestos (a substance hazardous to the respiratory system) in the workplace but was unlikely to suffer adverse effects from this exposure. Because of this concern among the comparison population, it is unlikely that the increased prevalence rates reported in the entertainment industry were due to a greater concern of a workplace exposure in this group. As mentioned in section 5.3.5, this comparison group would have had some exposures to respiratory irritants which may have led to higher prevalence rates than those which may have been found in an unexposed comparison group. For comparisons within the entertainment industry group only, increased odds ratios were found for cumulative exposure and work-related cough, phlegm, wheezing, and chest tightness (p O.05 for cough and phlegm only). The percentage predicted values for baseline FVC and FEV1 were lower in the entertainment industry. However, internal comparisons, within the entertainment industry using linear multivariable models, found no significant associations with FEV1 and FVC and cumulative exposure to theatrical smoke over 2 years but found a significantly positive association with FEV1/FVC and this exposure variable. This result for FEV1/FVC was unexpected and maybe due to the 70 short amount of time allowed to conduct lung function testing; this may have led to premature termination causing a lower value for FVC. For the acute symptoms, personal aerosol concentration on the study day was significantly associated with reporting 2 or more nose/throat/voice symptoms. The use of glycol-based theatrical smoke was significantly associated with increased dryness and central nervous system symptoms. For cross-shift lung function, no significant associations were found for any acute exposure parameters and change in FVC. Glycol- based theatrical smoke had a significantly positive association with cross-shift change in FEV1 and when glycol was substituted with mineral oil, it was associated with a negative change that approached significance (p=0.1). 7.2 Interpretation of Chronic Respiratory Symptoms Increased prevalence of all of the chronic respiratory symptoms (cough, phlegm, wheeze, chest tightness, shortness of breath on exertion) were found in the entertainment industry group. Symptoms exacerbated by work factors and onset associated with employment were also assessed; increased reported rates for 4 out of 5 of these work-related symptoms (phlegm, wheeze, chest tightness, and nasal symptoms) were found in the entertainment industry group. For internal comparisons within the entertainment group only, cumulative exposure to theatrical smoke was positively associated with work- related cough, phlegm, wheezing, and chest tightness (p<0.05 for cough and phlegm only). These are all symptoms linked to respiratory irritation. Chest tightness and wheeze are "asthma-like" symptoms. Cough, sometimes is associated with asthma but is 71 also a symptom of non-specific irritation. Phlegm is a symptom of chronic bronchitis and shortness of breath is usually associated with chronic obstructive lung disease. The NIOSH study did not find any association between occupational asthma and exposure to theatrical smoke (Burr, Van Guilder et al. 1994). However, it was mentioned that the low response rate of 62% limited the ability to detect differences between theatrical smoke- exposed and non-smoke exposed performers and diminished the reliability of the findings. It could not be determined if the chronic exposure to theatrical smoke was predominantly glycol-based or mineral oil-based as workers would not have been aware of the type of theatrical smoke used. However, there is support for both types of theatrical smoke in causing phlegm from chest. Short-term inhalation of propylene glycol (a component of some theatrical smokes) has been found to aid in the production of sputum in a clinical study (Olsen, Froeb et al. 1961); one may hypothesize that chronic exposure to propylene glycol (or glycol-based theatrical smokes) could lead to phlegm from chest over the duration of exposure. Mineral oil mists used as metal working fluids and found in occupational settings have been associated with chronic cough and chronic phlegm. Metal working fluids contain impurities that are not found in the highly refined food- grade mineral oil used to create theatrical smoke, so it is not possible to determine if these impurities in metal working fluids lead to the adverse effects on respiratory health or if it is the mineral oil itself. Although cumulative exposure did not differentiate between glycol or mineral oil-based theatrical smokes, an association to phlegm from chest was found. This association is supported by previous work which reported that mineral oil mists or glycol mists have the potential to cause phlegm from chest symptoms. Further to this, as mineral oil mist exposure has also been associated with 72 chronic cough, it is possible that the cumulative exposure variable may act as a surrogate for cumulative exposure to mineral oil; this hypothesis would also support the associations between cumulative exposure and chronic cough and phlegm. Although previous studies did not look at chronic symptoms in relation to chronic exposure, the higher prevalence of work-related sneezing and nasal symptoms found in the entertainment industry is consistent with previous findings. The NIOSH study found a significantly higher prevalence of nasal symptoms reported by performers working in theatrical smokes productions for the previous workweek when compared to those working in non-theatrical smoke productions (Burr, Van Guilder et al. 1994) and the Actor's Equity Study found that actors working in productions using theatrical smoke productions reported a 53% prevalence rate of nasal congestion in the previous month (Moline, Golden et al. 2000). Internal comparisons within the entertainment industry group did not find a significant association with cumulative exposure and chronic nasal symptoms, this finding was unexpected given the previous findings mentioned and the increased prevalence in the entertainment industry group. 7.3 Interpretation of Lung Function Results Both FVC and FEV1 were lower in the entertainment industry versus the comparison population. A significant positive association was found between FEV1/FVC and cumulative exposure to theatrical smoke over 2 years. Although, cross-shift FVC and FEV1 were not associated with personal aerosol concentration or technician-reported time spent in an environment with theatrical smoke, FEV1 had a significant positive 73 association with the use of glycol-based theatrical smoke. As mentioned earlier, with mineral oil replacing glycol in the model, a negative association was found which approached significance (p=0.1) and it was not possible with stratification to determine whether glycol is having a positive effect or mineral oil is having a negative effect on FEV1; stratifying by type of theatrical smoke did not reveal any significant associations between personal aerosol concentration and FEV1. Previous studies would support the hypothesis that mineral oil has a negative effect on FEV1. The Actor's Equity study found that actor's with the greatest exposure to mineral oil (~3.7mg/m3) had significant decreases in FVC and FEV1. Actor's with exposure to mineral oil at >1.48mg/m3, had statistically significant decreases in FVC only. However, no clinically significant changes in lung function were associated with exposure to glycol-based theatrical smoke (Moline, Golden et al. 2000). In addition, previous studies of mineral oil mists in occupational settings have found significant decreases in FEV1 associated with exposures (Ameille, Wild et al. 1995). 7.4 Interpretation of Acute Symptoms For acute symptoms, increased aerosol mass is associated with upper airway (nose, throat, voice) symptoms but is not a good predictor of other acute responses measured. The use of glycol-based theatrical smoke is a better predictor of increased dryness, CNS, and irritative eye symptoms. These results are supportive of findings in previous studies. The Actor's Equity study found significant positive associations between glycol-based theatrical smoke and reporting of any throat, irritated throat, phlegm and coated vocal cords and voice change, and any nose symptoms (Moline, Golden et al. 2000). Glycols 74 are hygroscopic in nature and as suggested from an inhalation study of propylene glycol in rats (Suber, Deskin et al. 1989), it would be expected that they would have a drying effect on mucous membranes. The NIOSH study found that actors in theatrical smoke productions reported a greater prevalence of nasal symptoms (sneezing, runny or stuffy nose), respiratory symptoms (cough, wheeze, breathlessness, chest tightness), and mucous membrane symptoms (sore throat, hoarseness, dry throat, itchy burning eyes, dry eyes) during their performances in the week previous to completing the survey (Burr, Van Guilder et al. 1994). 7.5 Strengths of the Study Overall, the cross sectional study had a relatively good participation rate once production sites were identified while previous studies had suffered from poor participation rates (Burr, Van Guilder et al. 1994). Previous occupational studies had been confined to Broadway musicals and performers; the cross-sectional study was the first study to include diverse types of productions and jobs. This inclusive aspect of the study allowed for the analysis of health outcomes from a variety of exposure scenarios and employees not previously assessed in other studies. There were many strengths related to exposure measurements and collection of health data over previous studies. Subjects completed an acute symptoms questionnaire before and approximately 4 hours after exposure to smoke with personal exposure monitoring conducted during the exposure duration. During this exposure monitoring period, subjects also were monitored by an industrial hygienist for time spent in theatrical smoke 75 which would lower bias compared to self reports. This timing of the exposure monitoring alongside collection of symptoms data is a strength over previous work which looked at qualitative exposure (smoke or non-smoke production) and an exposure matrix to estimate exposure to theatrical smoke (Burr, Van Guilder et al. 1994; Moline, Golden et al. 2000). In the longitudinal actor's equity study (Moline, Golden et al. 2000), an exposure matrix was created from exposure monitoring for 1 day on each site used over the course of the study. It was assumed that exposures stayed consistent over the course of a production. The cross sectional study was the only study thus far which was able to assess the association between chronic respiratory and skin symptoms and estimated cumulative exposure. Estimated cumulative exposure was based on multiple questions related to chronic exposure over 2 years and was weighted based on exposure assessment data. As employees would not know the values of the weighting, the estimated cumulative exposure had a strength in that it was not completely related to self-reported data. Factors which improve self-reporting (and were present in this study) include: the ability to easily sense exposure to the agent; and the querying of the subject about the exposure (Teschke, Olshan et al. 2002). Concern exists on whether health status influences self- reported exposure. However, most investigators have found little or no difference in validity or reliability of self-reported exposure assessments when case and control populations were compared (Teschke, Olshan et al. 2002). 76 7.6 Limitations of the Study Because of the difficulty in obtaining access to worksites, convenience sampling was utilized. It was not possible to assess a proper site participation rate as many productions were refusing due to the perceived inconvenience of having a research team on site. Many sites had reported not using theatrical smoke but often it was not possible to verify this information. Additionally, several sites refused to participate and sited current employee complaints about the use of theatrical smoke and a concern about an increased level of concern among employees if a research team visited a set to investigate fogs. As a result, site participation would not have been representative of all exposure scenarios which would occur on productions. Most likely, productions which had problems with employee health related to theatrical smoke exposure would have not been included in the study. This restriction would likely lead to more conservative estimates on the health effects from exposure to theatrical smoke. A smaller sample size was obtained than that originally planned which limited the ability to conduct some stratified analyses. It was not possible to look separately at employees acutely exposed to mineral oil, glycol-based theatrical smoke to determine if either compound was associated with less symptoms or if different glycols used in creating theatrical smoke may have been associated with fewer symptoms. Additionally, it was not possible to conduct testing on performers. The number of subjects reporting work-related voice problems was low (n=2). It is possible that 77 performers' would be more sensitive in noticing subtle changes affecting their voices compared with non-performing crew as their ability to work would depend on their voice. With the cross-sectional study design, association can be established but it is impossible to determine causation as exposure and responses are determined at the same time (Gordis 2000). Additionally, symptom prevalences may be underrepresented as employees suffering severe effects from exposure to theatrical smoke may seek work on productions where theatrical smoke is not used. Differences in prevalence rates between the comparison population and the entertainment industry group maybe conservative since the comparison population would have had some exposures to respiratory irritants. The entertainment industry group may have had higher differences in prevalence rates or possibly more symptoms may have shown statistically significant differences if a control population was used which did not have exposures to respiratory irritants. 78 7.7 Summary Limited studies have been conducted previously on the health effects from exposure to fogs; previous work was restricted to Broadway musicals. Due to poor participation rates, findings from these studies were limited and uncertainty existed about applying these findings to other work environments (such as television/film production, music concerts, and arcades). It was believed that exposure levels differed in live musical productions seen on Broadway. These musicals would typically last for a few hours but could result in high peak levels compared with those on television/movie production which could last for the course of a workday. Because of these possible differences in exposure levels, it was believed that possible risks to health may differ based on the type of production. Additionally, no information had been collected in previous studies to assess health effects from long term exposure to fogs. For these reasons, a cross sectional study was conducted on employees within the BC entertainment industry and consisted of a wide variety of production types. This study collected data on short and long term exposures along with the potential health effects by assessing acute and chronic health symptoms. With respect to the initial study objectives in Section 4, at least one subject on any given sampling day was to be from the makeup department as concern existed over their additional exposure to glycols which are also found in cosmetics. Makeup technicians ended up making up less than 10% of the study population. As a group, makeup personnel were highly correlated with exposure level and it was not possible to assess the possible difference in health effects related to being a makeup technician. The health 79 status of costume personnel was another area of concern as they would have exposures to cleaning fluids in addition to theatrical smoke. This group made up less than 5% of the study population and was highly correlated with acute exposure variables so it was not possible to add this variable into the health effects models. For these reasons, it was not possible to assess the effects of additional exposures in costume technicians. Chronic health effects resulting from exposure to fogs were dually assessed: 1) external comparisons with a control population, and 2) internal comparisons within the entertainment industry group, specifically looking at the relation to exposure factors. The external comparisons reveal that the entertainment industry group exhibits poorer respiratory health compared with the control population when looking at basic indicators (chronic, work-related symptoms and lung function) of respiratory health. Work-related symptoms were defined as having an onset after the age of 16 and worsening related to work factors. For these work-related symptoms, significant increases were found for chest tightness and nasal symptoms among the entertainment industry group. These findings may suggest an association between exposure to fogs and chronic respiratory symptoms but uncertainty would still remain as these findings are comparing employees working in entertainment productions with those working on ships. It is possible that exposures apart from fogs between the 2 groups maybe causing the increase in chronic symptoms found in the entertainment industry group. Therefore, internal comparisons were conducted using the entertainment industry group only. These comparisons looked at chronic work-related symptoms and their relation to long-term 80 exposures to fogs after accounting for other important factors (age, sex, smoking status, and atopic status) that could have an impact on chronic symptoms. From these internal comparisons, increased exposure to fogs was associated with increased reporting of work-related cough and phlegm. The external comparisons did not show any significant increases in either of these symptoms; work-related phlegm had a 1.3% higher prevalence in the entertainment industry group and work-related cough had a 4% higher prevalence in the control group. It is possible that 2 factors may account for this inconsistency between findings in the internal analyses and the external comparisons. As mentioned previously in Section 7.6, the comparison population was not the ideal control population as there would have been exposures to other respiratory irritants. These exposures could then have resulted in higher prevalence rates of respiratory symptoms (in this control population compared to an unexposed population) which may explain the higher rates of work-related cough in the comparison population when compared to the entertainment industry group. Additionally, these potentially elevated rates in the control population may have lead to fewer differences found in comparisons to the entertainment industry. It is possible that comparisons using a control group not exposed to respiratory irritants may have showed a greater increase in respiratory symptoms among the entertainment industry group and leading to statistical significance for these symptoms. The second factor that may have caused problems was the small sample size for both control and entertainment industry groups. With the small sample size, symptoms showing strong differences in prevalence rates between the 2 groups were statistically significant. It is possible that with a larger sample size, that prevalence rates which were only slightly elevated in the entertainment industry for other symptoms may have approached significance. 81 Due to the low number of subjects with work-related asthma, an analysis of the relationship with exposure to fogs could not be performed. Previous study findings gave no support that exposure to fogs causes work-related asthma; however, it was noted that the low participation rate limited the reliability of the findings (Burr, Van Guilder et al. 1994). As mentioned in Section 3.3, many of the glycols used in creating theatrical smoke were found to cause allergic contact sensitization in a small percentage of study populations (Maibach 1975; Hannuksela and Forstrom 1976; Fisher 1977; Hannuksela and Forstrom 1978; Angelini, Vena et al. 1985; Bajaj, Gupta et al. 1990; Catanzaro and Smith 1991; Johansen, Jemec et al. 1995; Sugiura and Hayakawa 1997; Diegenant, Constandt et al. 2000). Further to this, dermal contact sensitization has also been associated with chemical respiratory hypersensitivity (Kimber 1996). Given that these symptoms may cause sensitization in a small proportion of the population, it is possible that the sample size of this study was too small to detect such an association if in fact one exists. The 'healthy worker' effect may also have played a factor in limiting the number of subjects with work-related asthma. Subjects were selected on sites where fogs were used on the day of testing. If there were individuals suffering from asthma related to theatrical smokes exposure, they likely would have chosen productions where fogs were not used or may have chosen to not work on a given set if fogs were being used for that day. While findings did not support an association between work-related asthma and exposure to fogs, reliability is reduced due to the aforementioned limitations. Similarly, there was also a low number of subjects with work-related voice problems which made it not possible to analyze the relation with exposure to fogs. A previous study on performers, found minor voice problems associated with glycol fog (Moline, 82 Golden et al. 2000); such subtle voice problems may be more noticeable among performers. The study population (which did not include performers) may not have noticed voice problems as being severe enough to interfere with their work since their jobs would not rely heavily on their vocal abilities. Acute symptoms and cross shift lung function related to exposures on the sampling day were also assessed. There were no significant associations between acute cough or chest symptoms and exposure to fogs on the sampling day nor with the type of fog used on the sampling day. However, the reporting of nose/throat or voice symptoms was associated with personal aerosol concentration; a finding which is supported by previous studies (Moline, Golden et al. 2000; Weislander, Norback et al. 2001; Greenbaum, Leznoff et al. 1988). Dryness, CNS, and eye symptoms are linked to an expected chemical specific effect of glycols rather than that of general particulate since these symptoms were significantly associated with the use of glycol-base theatrical smoke but were not associated with personal aerosol concentration. Again, these findings are supported by previous studies (Moline, Golden et al. 2000; Weislander, Norback et al. 2001; LaKind, McKenna et al. 1999). While a statistically significant increase in FEV1 was associated with the use of glycol-based theatrical smoke, a decrease which approached significance was associated with the use of mineral-oils. Previous work supports the finding that mineral oils would be causing a decrease in FEV1 but do not support an effect on FEV1 from exposure to glycols (Moline, Golden et al. 2000). In conclusion, there were no findings which linked exposure to theatrical smoke and fog to skin rashes, or voice problems. However, significant effects on respiratory health were 83 found. A main objective of the study involved determining which methods and components maybe associated with causing fewer symptoms. The findings indicate that both mineral oil and glycol-based fogs are associated with adverse effects on respiratory health. Both types of fog are associated with causing upper respiratory irritation with short term exposure (nose, throat, or voice problems), and chronic nasal symptoms with chronic exposure. In addition to this, short term exposure to glycol fogs are causing mucous membrane irritation while mineral oil appears to be causing effects in the lower respiratory system. Long term exposure, which did not differentiate between the type of fog used, was also associated with irritation of the lower respiratory system. It should be noted that while roughly half the study subjects were exposed to mineral oils and the other half exposed to glycols, site participation would not have been representative of the entertainment industry in general. It would not be valid to assume that both types of fog have the same levels of use on productions in general. One type of fog might be used most often than the other. In this case, cumulative exposure may be a surrogate for exposure to a specific type of fog which could mean that one type of fog rather than both may be causing chronic respiratory health impacts. Further work in this area should be conducted to determine whether chronic exposure mineral oil or glycol based fogs is more strongly or similarly associated with chronic respiratory effects. 84 Table 7-1 Comparison of Findings with Previous Studies Thesis Findings Findings in Previous Studies Animal Studies Increased prevalence of chronic Increased prevalence of Not measurable in animals respiratory symptoms and nasal respiratory, nasal and mucous symptoms compared to the membrane symptoms in comparison population performer's working in 'smoke' productions compared with those working in 'non-smoke' productions (Burr, Van Guilder et al. 1994). Increased risk of respiratory Previous studies had not assessed Not measurable in animals symptoms with increases in ongoing symptoms and their cumulative exposure relation to long- term exposure Increased acute upper airway Increased throat symptoms Not measurable in animals (nose, throat, voice) symptoms associated to both glycol and were associated with increased mineral oil exposure. personal aerosol concentration Nasal and voice symptoms was but not significantly associated to associated with increasing either glycol or mineral oil exposure to glycols (Moline, exposure Golden.et al. 2000). Throat symptoms were increased in a controlled inhalation study of propylene glycol (Weislander, Norback et al. 2001). A clinical study comparing 2 nasal sprays found that the nasal spray with the lower amount of propylene glycol caused less nasal burning, stinging and throat irritation. Increased acute dry throat, dry Increased respiratory and throat Inhalation to high levels of cough, increased CNS and symptoms associated with propylene glycol in mice found irritated eye symptoms were exposure to glycols glycols nasal hemorrhage and ocular associated with exposure to (Moline, Golden et al. 2000). discharge believed to be caused glycols Throat dryness associated with by the dehydrating effects of increased exposure to propylene propylene glycol (Suber, Deskin glycol in controlled human study etal. 1989). (Weislander, Norback et al. 2001). Clinical effects in humans of ethylene glycol have been found to cause CNS depression (LaKind, McKenna et al. 1999). Decreased average values for Decreases in FVC and FEV1 was Not measurable in animals FEV1 and FVC compared to linked with exposure to mineral control population oil based theatrical smoke glycols. No changes in FEV1 or FVC associated with exposure to glycols (Moline, Golden et al. 2000). No association found between No increased risk of occupational Not measureable in animals exposure to theatrical smoke and asthma from exposure to occupational asthma. theatrical smoke (Burr, Van Guilder etal. 1994). 85 7.8 Comparison of Risks and Recommendations Relative to other known health risks such as cigarette smoking, the risks from exposure to theatrical smoke are considerable. A one unit increase in the cumulative exposure variable represents an increase of working for 6 months on a production using theatrical smoke while for the current smoker packyears variable, one unit represents smoking one pack per day for one year for a current smoker. Odds ratios are roughly equal to 'relative risks' and an odds ratio of 1 indicates no difference in risk of having a symptom given presence of the exposure factor for dichotomous variables or given a one unit increase in the exposure factor for continuous variables; an odds ratio of 2 means a doubling of the risk of having the symptom, given the specified exposure; an odds ratio of 0.5 indicates approximately half the risk for the symptom, given the exposure. The risk for work-related cough was nearly doubled (OR=1.8) with a one unit increase in cumulative exposure while it was only slightly increased (OR=l.l) for a one unit increase in current smoker packyears. For work-related phlegm, two and a half times is found (OR=2.4) with cumulative exposure while for current smoker packyears there was no increased risk (OR=1.0). For both work-related chronic symptoms, the risk from working in an environment with theatrical smoke for 6 months is considerably higher than the risk of smoking one pack per day for one year. 86 For acute upper respiratory symptoms (nose, throat, or voice), a lmg/m3 increase in aerosol concentration over the testing period gives over double the risk (OR=2.2) compared to only a slight increase (OR=l.l) for each increase in the number of cigarettes smoked over the same time. The risk for acute dry throat or dry cough is almost 5 times (OR=4.9) for exposure to glycol-based fogs and a one and a half increase (OR=1.5) for the number of cigarettes smoked. The risks from exposure to theatrical smoke are greater than that of cigarette smoking in the short term. With respect to occupational exposure limits, levels set by the Worker's Compensation Board of British Columbia (WCB) and the American Conference of Governmental Industrial Hygienists (ACGIH) should be considered. The WCB 8-hour exposure limit for severely refined oils (which include the food grade mineral oil used to create theatrical smoke) is 1 mg/m3 (WCB 1998). While the ACGLH time-weighted average Threshold Limit Value (TLV) for mineral oil mist is 5mg/m3, a 0.2 mg/m3 level has been proposed which would not distinguish between the type of mineral oil (ACGIH 1997). The arthimetic mean of personal exposures to mineral oil exceeded the 0.2 mg/m3 limit and neared those of the 1 mg/m3 exposure limit of the WCB. Mineral oil had a negative effect on FEV1 which was near significance (p=0.01) and this result was supported by previous work on exposure to oil mists. Effects on lung function have been seen at levels lower than the 1 mg/m3 limit of the WCB but higher than the proposed 0.2 mg/m3 limit of the ACGIH; suggesting that a more suitable limit would be 0.2 mg/m3. 87 The WCB 8-hour Exposure Limit and ACGIH 8-hour time weighted average TLV for glycerin mists (the only glycol compound used in theatrical smoke which is listed) is 10 mg/m3 which is also the same level as that for 'particulate not otherwise classified' (WCB 1998). Glycol mists not consisting of glycerin would fall into the latter category in terms of exposure limits. However, findings in this study would suggest that these exposure limits are not suitable as none of the personal exposures to glycols exceeded 3 3 this standard of 10 mg/m (the maximum exposure to glycol aerosols was 3.2 mg/m but the average of exposures was 0.49 mg/m ) and some acute health effects such as dry throat/dry cough, CNS, and irritative eye symptoms were strongly associated with glycol exposure. As exposure is showing a chemical specific effect due to the properties of glycols, rather than just due to particulate inhalation, it would be more appropriate to set specific levels for exposure to glycols. Since health effects were found at exposure levels of 3.2 mg/m3 or less, the exposure limit of 10 mg/m3 would not be appropriate. Because of the small sample size, it was not possible to determine levels of exposure in which health effects would not be expected. Further study would be needed to determine such levels. Appendix A :Consent Form and Questionnaires 89 UNIVERSITY OF BRITISH COLUMBIA ACUTE SYMPTOMS QUESTIONNAIRE 92 Pre-Air Sampling Name: Subject Number: [ ] Date: [ / / 2 0 0 1 ] Time: [ ] hour (24 hour clock) Interviewer's initial: How long have you been exposed to smoke since you started work today? (min) Before you started work today, have you experienced any of the following? How much did it bother you? NO YES Only a some very little much Irritated eyes Red eyes Watery eyes Itchy eyes Runny/stuffy nose Nose Bleeding Congestion Sneezing Sinus problems Sore throat Irritated throat Dry throat Dry cough Cough with phlegm Chest tightness Wheezing Breathlessness Nausea Stomach aches Drowsiness Dizziness Headache Tiredness Fever Skin irritation Voice problems Joint pains Any other symptoms? (specify) 93 Post-Air Sampling Name: Subject Number: [ ] Date: [ / / 2 0 0 1 ] Time: [ ] hour (24 hour clock) Interviewer's initial: Since our previous interview, have you experienced any of the following? Compared to the earlier, How much did it interview today is this: bother you? NO YES better no worse only a some very change little much Irritated eyes Red eyes Watery eyes Itchy eyes Runny/stuffy nose Nose Bleeding Congestion Sneezing Sinus problems Sore throat Irritated throat Dry throat Dry cough Cough with phlegm Chest tightness Wheezing Breathlessness Nausea Stomach aches Drowsiness Dizziness Headache Tiredness Fever Skin irritation Voice problems Joint pains Any other symptoms? (specify) 94 Name: Subject Number: [ Date: [ / / 2 0 0 1 ] Time: [ ] hour (24 hour clock) Interviewer's initial: Since our previous interview, how many hours (or minutes) have you spent in an environment in which visible smoke was present? Hrs Min How many cigarettes have you smoked since our previous interview? 95 University of British Columbia Theatrical Smokes Respiratory Questionnaire Part One: Personal Characteristics The following information will help us to keep in touch with you and will be important to us as we measure your health status. It is confidential and will not be released to another party without your permission, row [01] SITE[ ] VISIT [ ] SUBJECT [ ] STUDY[4 5] 3-12 Today's Date[_ /__/2QQ1] Time [ ] 13-20 "3ay month year Interviewer (initials): L 1 [ ] 21-22 Full Name: Last [ ] 23"40 First [ ] 41 "53 Alternative Surname [ ] 53-67 or Maiden Name row [02] Address: Apt: [ ] 3"6 Street: [ ] 7"35 City/town: [ ] 36"55 Province: [ ] Postal Code [ - ] 56-64 Telephone: [ - ] 65"71 Name of Employer: Address of employer: (please be as specific as possible) row [03] Height: feet inches ([ ]cm.) 3-5 Weight: lbs ([ ]kg.) 6-8 Date of Birth: [ /__/ ] [ I9 Sex: 1. Male 2. Female [ ]10 For the purpose of lung function testing it is important that we know your genetic background: 1.white 2.oriental 3.First Nations [ ]11 4.eastindian 5.Black 6. Other Cold A. Do you currently have a cold? I.Yes 2.No [ ]12 B. Have you had a cold in the last 6 weeks? I.Yes 2.No [ ]13 96 PFT TEST RESULTS Test Date FVC FEV, MMF [ /_ /20011 Pre [_•__ __J 14-30 day monfrT year Post [ .J 31-39 ALLERGY SKIN TEST RESULTS: Measurement (mm) Check if not done Mixed Pacific trees J40-41 Mixed Pacific grasses ]42-43 Cat Epidermal antigen ]44-45 Dog antigen ]46-47 House dust mite ]48-49 Histamine ]50-51 Control J52-53 Part Two Health History These are questions mainly about your health. Please answer yes or no. If in doubt about the answer, please answer no. Cough Row[04] Do you usually have a cough? 1 .Yes 2.No [ ] 03 (count cough with first smoke or first going out of doors. Exclude clearing throat.) IF NO TO 'A', ask: Do you usually cough at all on getting up 1 .Yes 2.No [ ]04 or first thing in the morning? Do you usually cough at all during the I.Yes 2.No [ ] 05 rest of the day or night? IF YES TO ANY OF ABOVE, ask: Do you usually cough like this most days 1 .Yes 2.No [ ]06 for 3 consecutive months or more during the year? For how many years [ ][ ] 07-08 have you had this cough? numBero,years F. Does the cough improve: on days off? 1.Yes_ 2.No__ [ ] 09 on long holidays? 1.Yes_ 2.No_ [ ] 10 Is there anything or situation which makes your cough worse? 1 .Yes 2.No [ ] 11 ] 12-13 specify [ K 97 PHLEGM Do you usually bring up phlegm from 1 .Yes 2.No [ ] 14 your chest? (count phlegm with first smoke or first going out of doors. Count swallowed phlegm. Exclude phlegm from the nose.) IF NO TO 'A', ask: Do you usually bring up phlegm at I.Yes 2.No [ ] 15 all on getting up or first thing in the morning? Do you usually bring up phlegm at I.Yes 2.No [ ] 16 all during the rest of the day or night? IF YES TO ANY OF ABOVE, ask: Do you usually bring up phlegm like 1 .Yes 2.No [ ] 17 this most days for 3 consecutive months or more during the year? For how many years have you had [ ][ ] 18-19 , . . ... |_, o number of years trouble with phlegm? Does the phlegm improve: On days off? 1.Yes_2.No_ [ ] 20 IOs nther lone ganythin holidaysg or? situation which 1 .Yes 1.Yes_2.No2.No _ [ ] 22 [ ] 21 makes you bring up phlegm? [ ][ ] 23-24 specify CHEST COLDS AND CHEST ILLNESSES If you get a cold does it usually go to I.Yes 2.No [ ]3 your chest? (ie. more than half the time) During the past 3 years, have you had I.Yes 2.No [ ] 4 any chest illness that has kept you off work, indoors at home, or in bed? 98 WHEEZING Does your chest ever sound wheezy or whistling: A. When you have a cold? 1 .Yes 2.No [ ] 5 B. Occasionally apart from colds? 1 .Yes 2.No [ ] 6 C. Most days and nights? I.Yes 2.No [ ]7 IF YES TO'B' or 'C, ask: Is the wheeze associated with chest I.Yes 2.No [ ] 8 tightness or difficulty breathing? For how many years has [ ][ ]9-10 this been present? number of years F. Does the wheeze improve: on days off I.Yes 2.No [ ]20 on long holidays 1 .Yes 2.No [ ]21 G. Is there anything or situation which I.Yes 2.No [ ]22 makes you wheeze or wheeze worse? [ ][ 123-24 specify 99 CHEST TIGHTNESS Do you ever have episodes or attacks l.Yes 2.No [ ]25 of chest tightness? IF YES TO 'A', ask: Is the chest tightness associated with l.Yes 2.No [ ]25 difficulty in breathing? IF YES TO'B", ask: C. For how many years has this been present? [ ][ ]27-28 number ot years D. Do you have chest tightness and difficulty 1 .Yes 2.No [ ]29 breathing on most days? E. During the past year how many attacks 1. None [ ]30 did you have? 2. Afew(1-3) 3. Several(4-12) 4. Most days F. Does it improve: on days off? 1.Yes_ 2.No_ [ ]31 on long holidays? l.Yes 2.No [ ]32 G. Is there anything or situation which makes l.Yes 2.No [ ]33 your chest tightness worse? If yes: Exercise 1 .Yes_ 2.No [ ]34 Cold air l.Yes 2.No [ ]35 Tobacco smoke 1 .Yes 2.No [ ]36 Strong odour l.Yes 2.No [ ]37 Fumes or dust 1 .Yes_ 2.No [ ]38 Other, specify: [ ][ I 39-40 H. Is your chest tightness worse at any particular time of the year? l.Yes 2.No [ ]41 If yes, when: [ ][ ] 42-43 100 BREATHLESSNESS Are you troubled by shortness of breath 1.Yes__ 2.No_ [ ]44 when hurrying on the level or walking up a slight hill? IF YES TO 'A', ask: Do you have to walk slower than people 1.Yes_ 2.No_ [ ]45 of your own age, on the level, because of breathlessness? Do you have to stop for breath when 1.Yes_ 2.No_ [ ]46 walking at your own pace on the level? Do you ever have to stop for breath 1.Yes_ 2.No_ [ ]46 after walking about 100 yards (or a few minutes) on the level? For how many years have you had ^ [ ][ ] 48-49 shortness of breath? number ot years GENERAL CHEST QUESTIONS The following questions are about your lung health IN THE PAST 12 MONTHS: At any time in the past 12 months: Have you had wheezing or whistling in l.Yes 2.No [ ] 50 your chest, when you did not have a cold? Have you woken up with a feeling 1 .Yes 2.No [ ] 51 of tightness in your chest? Have you been woken by an attack l.Yes 2.No [ ] 52 of coughing? Have you been woken by an attack of 1 .Yes 2.No [ ] 53 shortness of breath? Have you had an attack of shortness of breath l.Yes 2.No [ ] 54 that came on during the day when you were not doing anything strenuous? Have you had an attack of shortness of breath 1 .Yes 2.No [ ] 55 that came on after you stopped exercising? Which of the following statements best describes your breathing? 1. I rarely get trouble with my breathing [ ] 56 2. I do get regular trouble with my breathing but it always gets completely better 3. My breathing is never quite right 101 NASAL SYMPTOMS row[06] Do you ever have sneezing, or an itchy, runny I.Yes 2.No [ ]3 nose when you do not have a cold? IF YES TO T, ask: A. For how many years has this been present? [ ][ H-5 number ot years Does this improve: on days off? 1 .Yes_ 2.No_ [ ]6 on long holidays? 1 .Yes_ 2.No [ ]7 2. Do you usually have a stuffy or blocked nose? I.Yes 2.No [ ]8 IF YES TO '2\ ask: A. For how many years has this been present [ ][ ]9-10 number ot years B. Does this improve: on days off? 1.Yes_ 2.No_ [ ]11 on long holidays? I.Yes 2.No [ ]12 IF YES TO T OR '2' OR BOTH, ask: 3. Is there any thing or situation that makes the I.Yes 2.No [ ]13 nasal symptoms worse? * if yes, specify: 4. Do you ever have nose bleeds? I.Yes 2.No [ ]14 IF YES TO '4', ask: A. For how many years has this been present? [ ][ ]15-16 number ot years B. Does this improve: On days off? 1.Yes_ 2.No_ [ ]17 On long holidays? I.Yes 2.No [ ]18 C. Have you ever had to seek medical treatment I.Yes 2.No [ ]19 for these nosebleeds? 102 VOICE SYMPTOMS 1. Do you usually have problems with your voice? 1. Yes 2. No [ ]20 IF YES TO'1', ask: A. Does the sound of your voice vary throughout the day? l.Yes 2. No [ ]21 B. Do you have to strain to produce voice? 1. Yes 2. No [ ]22 C. Does your voice usually sound creaky or dry? l.Yes 2. No [ ]23 D. For how many years has this been present? [ ][ ]24-25 number ot years E. Does this improve: On days off? 1.Yes_ 2.No_ [ ]26 On long holidays? l.Yes 2.No [ ]27 EYE SYMPTOMS Do you usually have burning, itching, watering 1 .Yes 2.No [ ]27 eyes? IF YES to'1', ask: A. For how many years has this been present? [ ][ ] 28-29 number ot years B. Does this occur on most days? 1 .Yes 2.No [ ]30 C. Does this improve: on days off? 1.Yes_ 2.No_ [ ]31 on long holidays? l.Yes 2.No [ ]32 D. Is there any thing or situation which makes your eye symptoms worse? l.Yes 2.No [ ]33 If yes, specify: [ ][ ]34-35 103 SKIN SYMPTOMS row [07] Do you often have skin rashes? I.Yes 2.No [ ]1 (current) IF YES toT, ask: A. For how many years has this been present? [ ][ ]2-3 number ot years B. Do they occur: 1. Intermittently 2.year round [ ]4 3.seasonal 4. less often C. Is this rash: itchy? 1 .Yes_ 2.No [ ]5 scaley? 1 .Yes_ 2.No [ ]6 red? 1 .Yes_ 2.No [ ]7 weeping? 1 .Yes_ 2.No [ ]8 blisters? I.Yes 2.No2.No _ [ ]9 D. Is the rash located generalized? 1 .Yes_ 2.No_ [ ]10 on the hands? 1 .Yes_ 2.No_ [ ]11 on the foot? 1 .Yes_ 2.No_ [ ]12 on the face? 1 .Yes_ 2.No_ [ ]13 on the legs? 1 .Yes_ 2.No_ [ ]14 on the trunk? I.Yes 2.No [ ]15 Does the rash improve: On days off? 1 .Yes 2.No_ [ ]16 On long holidays? I.Yes 2.No_ [ ]17 Is the rash worse in the: 1. winter 2. Summer_ [ ]18 3. no difference H. Has the rash caused you to miss work? 1 .Yes 2.No [ ]19 I. Have you consulted a doctor about the rash? I.Yes 2.No [ ]20 IF YES to T, ask: Was the doctor a 1 .Family doctor 2. Dermatologist [ ]21 B. What was the diagnosis? [ ]22 2. Have you ever had eczema? I.Yes 2.No [ ]23 (scaly, itchy rash in flexures of the body) IF YES TO '1', ask: A. Do you still have it? 1.Yes_ 2.No_ [ ]24 B. Was it confirmed by a doctor? 1 .Yes 2.No [ ]25 DC. AIf tyo whau nt oag longee didr havit starte it?, at what age [ [ ][] [ ]28-2]26-297 years did it stop? years 104 Skin Symptoms (Cont) 4. Have you ever had a rash as a result of contact with any of the following: metals? I.Yes 2.No [ ]30 leather? I.Yes 2.No [ ]31 plants? I.Yes 2.No [ ]32 rubber? I.Yes 2.No [ ]33 adhesive? I.Yes 2.No [ ]34 cosmetics? I.Yes 2.No [ ]35 medicines? I.Yes 2.No [ ]36 PAST HISTORY OF ATOPY 1. Have you ever had asthma? I.Yes 2.No [ ]37 IF YES TOT, ask: A. Do you still have it? 1 .Yes_ 2.No_ [ ]38 B. Was it confirmed by a doctor? I.Yes 2.No [ ]39 C. At what age did it start? [ ][ 140-41 year D. If you no longer have it, at what age did it stop? years [ ][ ]42-43 2. Have you ever had hayfever? I.Yes 2.No [ ]44 (runny nose, sneezing in the spring) IF YES TO'1', ask: 1 .Yes_ 2.No_ [ ]45 A. Do you still have it? I.Yes 2.No [ ]46 B. Was it confirmed by a doctor? [ ][ ]47-48 C. At what age did it start? years D. If you no longer have it, at what age [ ][ ]49-50 did it stop? years PAST ILLNESSES row[08] A. Did you have any lung trouble before I.Yes 2.No [ ]3 the age of 16? Have you ever had any of the following: IF YES: Age Started Attacks of bronchitis Was it confirmed by a doctor? 1.Yes_ 2.No_ I.Yes 2.No [ ][ LJ4-7 Immune deficiencies 1.Yes_ 2.No_ I.Yes 2. No [ K JLJ8-11 Chronic bronchitis I.Yes 2.No I.Yes 2.No [ ][ ]LJ 12-15 Emphysema I.Yes 2.No I.Yes 2.No [ ][ ]LJ 16-19 105 Pulmonary tuberculosis 1.Yes_ 2.No_ 1.Yes_ 2>No_ [ ][ ]LJ 20-23 6. Pneumonia 1.Yes_ 2.No_ 1.Yes_ 2.No_ [ ][ ][ ] 24-27 IF YES TO '6', ask: How many times have you had pneumonia? . [ ][ ]28-29 " times Age at first episode: [ ][ ]30-31 years Age at last episode: [ ][ ]32-33 years C. Have you ever had any other chest illnesses? 1 .Yes 2.No ]34 If yes, specify D. Have you ever had any chest injuries? 1 .Yes 2.No ]35 If yes, specify E. Have you ever had any chest operations? 1 .Yes 2.No ]36 If yes, specify F. Are you currently taking any medications for 1 .Yes 2.No ]37 your breathing? If yes, specify (code 1 if chest illness, injury, or operation interferes with current lung function) ]38 Has a doctor ever told you that you 1 .Yes 2.No ]39 had heart trouble? If yes, have you had treatment for l.Yes 2.No [ ]40 Heart trouble in the past 10 years? Has a doctor ever told you that l.Yes 2.No [ ]41 you had high blood pressure? If yes, have you had treatment for high 1 .Yes 2.No [ ]42 blood pressure in the past 10 years? I. Do you have any other health problems? 1 .Yes 2.No [ ]43 If yes, specify: Are you taking any medications for other 1 .Yes 2.No [ ]44 Illnesses at present? If yes, specify: *code 1 if other illness(es) interfere with current spirometry [ ]45 Currently, would you say your overall health is: 1. Excellent [ ]46 2. Good 3. Fair 4. Poor 5. Bad 106 extra code: [ ]47 The following questions are about some habits which are important to us in evaluating your health. Please answer to the best of your memory. TOBACCO SMOKING row[08] SMOKING BY PEOPLE LIVING AROUND YOU: When you lived at home: A. Did your father smoke? 1 .Yes_ 2.No_ [ ]3 B. Did your mother smoke? I.Yes 2.No [ ]4 In your current household C. Do any members of your current household 1 .Yes 2.No [ ]5 smoke? (other than you) YOUR SMOKING CIGARETTE SMOKING D. Have you ever smoked cigarettes? I.Yes 2.No [ ]6 (No means less than 20 packs of cigarettes or less than one cigarette a day for one year) IF YES TO'D', ask: Do you now smoke cigarettes? (as of 1 I.Yes 2.No [ ]7 month ago? How old were you when you first started [ ][ ]8-9 regular cigarette smoking? years If you have stopped smoking cigarettes [ K J10-11 completely, how old were you when you years stopped? 4. How many cigarettes do you smoke per day [ ][ ]12-13 now? cigarettes per day 5. On average, for the entire time that you [ ][ ]14-15 smoked, how many cigarettes did you cigarettes per day smoke per day? PIPE SMOKING Have you ever smoked a pipe regularly? I.Yes 2.No [ ]16 (Yes means more than 12oz. of tobacco in a lifetime) IF YES TO 'E', ask: 107 How old were you when you first started [ ][ ]17-18 to smoke a pipe regularly? years If you have stopped smoking a pipe " - [ ][ ] 19-20 completely, how old were you when years you stopped? 3. How much pipe tobacco do you smoke [ ][ ]21-22 per week, now (one pouch=2oz)? ounces per week TOBACCO SMOKING (Cont) On average, for the entire time that you [ ][ ]23-24 smoked a pipe, how much pipe tobacco ouncesperweeK did you smoke per week? CIGAR SMOKING F. Have you ever smoked cigars regularly? l.Yes 2.No [ ]25 (Yes means more than 1 cigar/week for 1year) IF YES TO'F', ask: How old were you when you first started [ ][ ]26-27 Smoking cigars regularly? years If you have stopped smoking cigars Completely, how old were you when you [ ][ J28-29 stopped? years How many cigars do you smoke per week [ ][ ]30-31 now7 cigars per week 4. On average, for the entire time that you [ ][ ]32-33 smoked cigars, how many cigars did you c'9arsperweeK smoke per week? 108 PART THREE- FAMILY HISTORY As some illnesses are associated with childhood and family history, we would like to ask you about your family members, and about your childhood. Was your natural father ever told by a doctor that he had: 1 .yes 2.no 3. don't know Chronic bronchitis [ ]34 Emphysema [ ]35 Lung Cancer [ ]36 Asthma [ ]37 Other chest condition [ ]38 Hayfever [ ]39 Other allergic condition [ ]40 Was your natural mother ever told by a doctor that she had: 1 .yes 2.no 3. don't know Chronic bronchitis [ ]41 Emphysema [ ]42 Lung Cancer [ ]43 Asthma [ ]44 Other chest condition [ ]45 Hayfever [ ]46 Other allergic condition [ ]47 What was your country (province) of birth [ ][ ][ ]48-50 In what country did you spend the majority Of the first 10 years of your life? [ ][ ][ ]51-53 Were these first 10 years spent in the (check one only) countryside 1. [ ]54 town: smaller than 10 000 people 2. 10 000 to 100 000 people . 3. larger than 100 000 people 4. What was your father's usual occupation? [ ]55 What was your mother's usual occupation? [ ]56 109 PART 4-OCCUPA TIONAL PRESENT row [09] These questions are about your work on the production that I first interviewed you on. What is your present job status? [ ]3 1. employed, full time (theatre/production co./special effects co.) 2. employed, full time as day calls (theatre/production co./special effects co.) 3. Free lance day calls ( >2 times/week) 4. Free lance day calls ( <2 times/week) 5. Other__ specify Job Title: 1. stand in _ [ ][ ]4-5 2. actor 3. makeup technician _ 4. special effects technician 5. props technician 6. script hand 7. production assistant 8. camera person 9. musician 10. usher 11. other specify 3. Job Start Date __/__/__ 6-13 4. Total number of days worked [ ][ ][ ][ ]14-17 5. Location [ ]18 1. mostly indoors 2. mostly outdoors 3. both, about the same 6. How many days do/did you work per week? [ ]19 (on average) 7. How many hours do/did you work per day? [ ][ ]20-21 (on average) Of all the days that you have worked on this production, what % of days [ ][ ][ ]22-24 have you been exposed to visual effects smoke? % How many hours per day were you exposed to smoke? [ .J25-28 Usual location on set [ ]29 1. Working 10' or less from smoke/fog machine 2. Working inside studio/stage within 20' but not within 10' of smoke machine 3. Working inside studio/stage, but more than 20' from production set 4. Outside production set 11. Please describe the type of work you performed or are performing now : 110 OCCUPATIONAL PRESENT (Cont) 12. What chemicals or materials do you CURRENTLY work with (or are around) that may be hazardous, or that concern you: PART 5 - OCCUPATIONAL HISTORY- previous jobs with other employers These questions deal with your employment in the past 2 years. 1. 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CO O W T3 JZ CD _i E .E E o JO £ T3 ra CD : o •oo "o 5 -co CO I c ro o CO LU Q 2 CO CM tz CD >; CO jS ro o 00 [fl Q 2 CM JZ cz o ro 0 "ra 'ra JO w JZ o o 0^ ro ra CD it 0 0 w CL CL C a3 ^y s >> T o_ 3 ^ co ro h- -o i_ 0 ra ~ ZJ 0- .2'* cz -fzC L 5-"O ra ._, CM -CM A S/ U ro O i- o ZJ -1- i °| U0. L U L (1 p CO "CO ra ro '—' CN ••CM CO Q. CO CL O CZ C g LO CO "o CO CO 00 oo CO 5 LO 5 LO 5 LO LO O CM 5 5 LO I = O CM O CM O CM I O CM CT co cr co or co or co or co PART SIX: OTHER EXPOSURES THIS SECTION TO BE ASKED OF ALL PARTICIPANTS: row[40] Have you ever worked in, or been exposed to any of the following for more than six months at a time: NO YES 1s Year how long(yrs) 1. Asbestos milling/manufacture t ] [ ] [ 13-7 2. Asbestos removal [ ] [ ] [ ] 8-12 3. Asbestos dust in other jobs [ ] [ ] [ J13-17 4. Brake or clutch repair U[ ] I J18-22 5. Boilermaking/ repair [ ] [ I [ ] 23-27 6. Building maintenance/repair ill ] [ ] 28-32 7. Construction [ H ll ] 33-37 What trade(s)? f 138-39 8. Shipbuilding or repair ] [ ] [ ] 40-44 9. Sawmill ] [ ] [ ] 45-49 y if yes, Cedar dust exposure? 1. Yes. 2. No [ ] 50 10. Painting ] [ ] [ ] 51-55 • if yes, with 2 component paint? 1. Yes. 2. No [ ] 56 11. Spray foam applications ] [ ] [ ] 57-61 12. Anaesthetic gases ] [ ] [ ] 62-66 13. Auto repair or manufacture ] [ ] [ ] 67-71 14. Chemical or rubber manufacture ] [ ] [ ] 72-76 row [41] 15. Drycleaning ] [ ] [ ] 3-7 16. Electronic equipment manufacture ] [ ] [ ] 8-12 17. Farm, nursery, landscaping work ] [ ] [ ] 13-17 18. Firefighting ] [ ] [ ] 18-22 19. Fishing/other maritime work ] [ ] [ ] 23-27 20. Flour or grain handling ] [ ] [ ] 28-32 21. Foundry or metal fabrication ] [ ] [ ] 33-37 22. Furniture making ] [ ] [ ] 38-42 OTHER EXPOSURES, Continued NO YES 1st Year how long(yrs) 23. Laboratory work ] [ ] [ ] 43-47 118 What type? _ ] 48-49 24. Longshoring [ 1 ._] 50-54 25. Metal processing [ ] ._] 55-59 26. Mining, quarrying [ ] 1 60-64 Type of minerals (and specify if worked underground) [ ] 65-70 [ ] 71-76 row [42] 27. Non-asbestos insulation ] [ ] [ ]3-7 (eg.fibreglass, mineral wool) 28. Nuclear testing/power plant ] [ ] [ ]8-12 29. Petroleum processing ] [ ] [ ] 13-17 30. Plastics manufacture ] [ ] [ ] 18-22 31. Plywood manufacture ] [ ] [ ] 23-27 32. Pottery ] [ ] [ ] 28-32 33. Pulp and paper ] [ ] [ ] 33-37 34. Railway maintenance work ] [ ] [ ] 38-42 35. Roofing ] [ ] [ J 43-47 36. Sandblasting ] [ ] L__J 48-52 37. Smelter ] [ ] [ ] 53-57 Type: [ ] 58-59 38. Steelmill ] [ ] [ ] 60-64 39. Textile milling or processing ] [ ] [ ] 65-69 v if yes, Cotton dust exposure? l.Yes 2. No [ ] 70 row [43] 40. Welding ] [ ] [ ] 3-7 Type:. [ ] 8-9 > if yes, in enclosed spaces? (fill in dates) ] [ ] [ ] 10-14 41. Wood treating ] [ ] L_ ] 15-19 119 QUESTIONS 1 - 5 TO BE ASKED OF ALL PARTICIPANTS 1. In any job, have you ever been exposed to a high concentration of gas, fumes or smoke that made you sick or sent you to first aid or to the doctor? 1. YES 2. NO [ IF 'YES' COMPLETE GASSING QUESTIONNAIRE. 2. Have you ever had any health problems apart from accidents or injuries, that you feel were caused by your current area of work? LYES 2. NO [ * if yes, specify: Have you ever had any health problems apart from accidents or injuries, that you feel were caused by a job with another employer? LYES 2. NO * if yes, specify: 4. Have you ever left a job for health reasons only? 1. YES 2. NO [ * if yes, What was the job and what was the nature of the problem? 5. Is there anything else you feel we should know about your health, your work, or your exposures at work or elsewhere? 120 Sitel.D. #: Participant's I.D. #: Personal Sample Form Name of Employee: Date: Job Title: Location: # personnel with same job title on site: 7.9 7.10 Calibration Information Teflon XAD-2 Sample vs Blank I.D. FOG- + FOG- XAD- + XAD- Pump I.D. Calibrator I.D. Start Finish Flowrate (L/min) 1. 1. 2. 2. 3. 3. Av erage lemp (Cl R.H. (%) Pressure 7.10.1.1 Measurement Start Time: Finish Time: Sampling time: Counter clock: PPE Worn: ( yes or no ) Types (i.e. gloves, respirator): 121 Participant's Job Title: Hour Min Task Distance Distance from Visible Comments (list all from primary primary/active smoke/fog that apply) source set present 00 Y N 10 20 30 40 50 00 10 20 30 40 50 00 10 20 30 40 50 00 10 20 30 40 50 00 10 20 30 40 50 00 10 20 30 40 50 00 10 20 30 40 50 Tasks: 1. Refilling fluids/maintenance on machine 2. Operating smoke/fog machine 3. Working within 10' of smoke/fog machine (ON) 4. Working inside studio/stage; within < 20' of production set 5. Working inside studio/stage; outside > 20' from the production set 6. 7. 8. Outside smoke/fog area (studio/stage) 122 Site I.D. Determinants of Exposure Form: (Sampling Day) Location: Date: Production Type: Motion Picture TV Theatre Music Other: Indoors vs Outdoors # of smoke/fog machines used: Machine #1 Machine #2 Make Make Model Model Type of fluid used Type of fluid used Amt of fluid used Amt of fluid used Name from MSDS Name from MSDS Bulk sample ID # BULK- Bulk sample ID # BULK- Effects created # Effects created # Machine #3 Machine #4 Make Make Model Model Type of fluid used Type of fluid used Amt of fluid used Amt of fluid used Name from MSDS Name from MSDS Bulk sample ID # BULK- Bulk sample ID # BULK- Effects created # Effects created # 1. source smoke (i.e. campfire) 2. large volume smoke 3. smoldering effect 4. atmospheric smoke (lighting purposes) 5. haze 6. low lying fog 7. coloured smoke 8. steam General Area Time ( ) Time ( ) Time ( ) Temp (°C) R.H. (%) Pressure 123 Machine #1 Machine #2 Machine #3 Machine #4 On Off Time On Off Time On Off Time On Off Time (sec) (sec) (sec) (sec) Total Total Total Total 124 Site I.D. #: Diagram of Sampling Location: Room Dimension: L = W = H = Volume: (include: distances between machine locations, area sampler locations, typical locations of sampled crew) 125 a. es 3 c |E cu u CU 3 IO |E cs u IK w a es '— CN c^l 3 CN cn CN tt a q 6 I oo CU CD i/3 Q 3 s x C/3 3 o + lE a o E CU es H o c/3 o es cs cu I 33 u < CS H e a o u a d es es |3 I OH '3 a u es IS E o 3 s- o n CA o s- lu CD -*-» CU IS 3 I' O es 3 U C/3 O O 3 3 6 3 s H CD o O o 173 -4—» •a E C/3 Real Time Monitors: Instant Readings (every 15 minutes) Time Nephelometer DataRAM APC Hour Min. 15 30 45 60 15 30 45 60 15 30 45 60 15 30 45 60 15 30 45 60 15 30 45 60 15 30 45 60 15 30 45 60 127 Appendix B: Correlations and T Test results for variables considered in models 128 T test Results for Variables Considered for Acute Symptom and Cross-shift Lung Function Modeling Teflon Technician- Self-reported Time Concentration Reported Time in in Fog/30 Personal (mg/m3) Fog/30 (FOGMIN30) mean (sd) (FOGTIM30) mean (sd) 95% CI mean (sd) 95% CI 95% CI Childhood asthma N 0.7619(0.9557) 2.9135(2.5167) 4.3303(3.3694) 0.5606, 0.9633 2.3833,3.4436 3.6206,5.0401 Childhood asthma Y 0.5274(1.0046) 2.5278(1.7434) 5.0833(3.3428) (n=12) -0.111, 1.1657 1.4201,3.6355 2.9594,7.2072 P 0.4 0.6 0.5 Atopic Status N 0.6701(0.9189) 2.8115(2.5332) 4.2594(3.5831) 0.4216, 0.9185 2.1267,3.4963 3.2907,5.2281 Atopic Status Y 0.8106(1.0107) 2.9348(2.3356) 4.6116(3.0968) (n=46) 0.5105,1.1108 2.2412,3.6284 3.692,5.5312 P 0.5 0.8 0.6 Female N 0.8022(1.0924) 3.1466(2.4434) 5.0137(3.4004) 0.5378, 1.0666 2.5551,3.738 4.1906,5.8368 Female Y 0.5937(0.5904) 2.2929(2.3463) 3.196(2.9572) (n=33) 0.3844, 0.8031 1.461, 3.1249 2.1474,4.2445 P 0.2 0.1 0.01 Makeup N 0.7573(0.9868) 2.9743(2.4584 4.542(3.4009 0.553,0.9617 2.4652,3.4834 3.8377,5.2463 Makeup Y 0.4965(0.6016) 1.7778(1.9579 3.1704(2.7389 0.034, 0.9589 0.2728,3.2827 1.0651,5.2757 P 0.4 0.2 0.2 Special Effects 0.6645(0.889) 2.8742(2.4581) 4.4129(3.4142) Technician N 0.4814, 0.8476 2.368, 3.3804 3.7098, 5.116 Special effects 1.5432(1.3976) 2.7917(2.2813) 4.5(2.8158) technician job title Y 0.3748, 2.7117 0.8844,4.6989 2.146,6.854 (n=8) P 0.1 0.9 0.9 Props N 0.7509(0.9693) 2.9282(2.4391) 4.5381(3.339) 0.5566,0.9452 2.4392,3.4172 3.8687, 5.2075 Props Y 0.1838(0.0404) 0.8889(1.262) 0.5556(0.4194) (n=3) 0.0835, 0.2841 -2.246,4.0238 -0.486,1.5975 P <.0001 0.2 <.0001 129 Costume N 0.7508(0.9808) 2.9892(2.4323) 4.5476(3.3463) 0.552,0.9495 2.4964,3.4821 3.8695,5.2256 Costume Y 0.4137(0.1915) 0.5333(0.6498) 1.9667(2.8514) (n=5) 0.176, 0.6514 -0.273,1.3401 -1.574,5.5072 P 0.02 <.0001 0.09 Playmaster N 0.775(1.0024) 2.648(2.4383 4.0667(3.3254) 0.5662,0.9837 2.1402,3.1558 3.3741,4.7592 Playmaster Y 0.3618(0.1075) 4.8667(1.1988) 7.6333(1.4181) (n=10) 0.2849,0.4386 4.0091,5.7242 6.6189,8.6478 P 0.0003 0.0001 <.0001 Arcade N 0.7825(1.0054) 2.6478(2.452) 4.0452(3.3377) 0.572,0.9931 2.1342,3.1613 3.3461,4.7442 Arcade Y 0.4247(0.1294) 4.6667(1.3166) 7.4848(1.4327) (n=ll) 0.2508,0.4247 3.7822,5.5511 6.5224,8.4473 P 0.0002 0.0004 <.0001 Acrolein N 0.569(0.7414) 2.6224(2.231) 4.1978(3.3399) 0.3996,0.7384 2.1126,3.1322 3.4346, 4.961 Acrolein Y 1.5889(1.4165) 4.1852(2.6027) 6.1944(2.6693) (n=18) 0.8845,2.2934 2.8909,5.4795 4.867,7.5218 P 0.008 0.01 0.02 Large Volume Smoke 0.745(0.9661) 2.9155(2.4346) 4.499(3.3451) N 0.5523,0.9377 2.4299, 3.4011 3.8318, 5.1662 Large Volume Smoke 0.1939(0.0111) 0.5(0.2357) 0.5(N/A) Y (n=2) 0.0941,0.2936 -1.618,2.6177 0.5, 0.5 P <.0001 0.2 <.0001 Source Smoke N 0.8002(1.0374) 3.4801(2.3959) 5.1152(3.3027) 0.5647,1.0356 2.9363, 4.0239 4.3655, 5.8648 Source Smoke Y 0.522(0.6205) 0.9028(1.2256) 2.1889(2.4872) (n=24) 0.26, 0.784 0.3852, 1.4203 1.1387, 3.2391 P 0.1 <.0001 0.0001 Smoldering Effect N 0.7528(0.9653) 2.7742(2.4402) 4.1763(3.1945) 0.554, 0.9517 2.2716, 3.2767 3.5184, 4.8343 Smoldering Effect Y 0.5159(0.92) 3.9542(2.2134) 7.25(4.1318) (n=8) -0.253, 1.285 2.1037, 5.8047 3.7958, 10.704 P 0.5 0.2 0.01 Atmospheric N 0.4752(0.6518) 1.4676(1.9319) 3.0324(3.5661) 0.2579,0.6925 0.8234,2.1117 1.8434,4.2214 Atmospheric Y (n=64) 0.8838(1.0754) 3.6771(2.3352) 5.2219(2.9755) 0.6151,1.1524 3.0938, 4.2604 4.4786,5.9651 P 0.02 <.0001 0.001 130 T Test Results for Chronic Symptom and Chronic Lung Function Hours in Smoke over 2 Intensity Weighted Hours in years/1000 JDURADJ Smoke over 2 years/1000 mean (sd) JINTENS 95% CI Mean (sd) 95% CI Childhood asthma N 0.9701 (1.1193) 0.7279(1.2968) 0.7343,1.2059 0.4547,1.0011 Childhood asthma Y 0.9977(1.7789) 0.3747 (0.7219) (n=12) -0.133,2.1279 -0.084, 0.8334 P 1.0 0.2 Atopic Status N 1.0046(1.2252) 0.6882 (1.2893) 0.6734, 1.3359 0.3396, 1.0368 Atopic Status Y 0.936(1.1915) 0.6832 (1.2044) (n=46) 0.5822,1.2898 0.3256,1.0409 P 0.8 1.0 Female N 0.9848 (1.1375) 0.6819(1.2539) 0.7094, 1.2601 0.3784, 0.9854 Female Y 0.9499(1.3503) 0.6943 (1.2463) (n=33) 0.4711,1.4287 0.2524, 1.1362 P 0.9 0.9 Makeup job title N 0.853 (1.0443) 0.5854(1.1296) 0.6367,1.0692 0.3515,0.8194 Makeup job title Y 2.2043 (1.9635) 1.7132 (1.8873) 0.695,3.7136 0.2625,3.1639 P 0.07 0.1 Special effects technician 0.9157(1.173) 0.5432(1.0157) job title N 0.6742,1.1573 0.334, 0.7524 Special effects technician 1.6433(1.4436) 2.3453(2.2743) job title Y (n=8) 0.4364,2.8502 0.4439,4.2467 P 0.1 0.06 Props job title N 0.9901(1.2162) 0.7017(1.2605) 0.7463,1.2339 0.449, 0.9544 Props job title Y 0.4267(0.5746) 0.1707(0.2298) (n=3) -1.001, 1.854 -0.4, 0.7416 P 0.4 0.02 Costume job title N 0.9891(1.2225) 0.6894(1.2626) 0.7414,1.2368 1.2626,0.9452 Costume job title Y 0.6715(0.8057) 0.6191(0.9466) (n=5) -0.329, 1.672 -0.556,1.7945 P 0.6 0.9 131 Playmaster job title N 1.0308(1.2475) 0.7477(1.2961) 0.771,1.2906 0.4778,1.0177 Playmaster job title Y 0.4509(0.469) 0.1236(0.1976) (n=10) 0.1154,0.7865 -0.018, 0.265 P 0.007 <.0001 Arcade N 1.0316(1.2544) 0.7552(1.3014) 0.7688,1.2943 0.4826,1.0278 Arcade Y 0.4972(0.4707) 0.1193(0.188) (n=ll) 0.181, 0.8134 -0.007,0.2457 P 0.01 <.0001 Correlated Variables of Interest Variable Variable Correlated Pearson Decision Grouping Variable Correlation Coefficient Personal Current Smoker Current Smoker 0.64 Current Smoker Factors Packyears Packyears used for chronic symptoms, current smoker status used for Lung Function Data Current Smoker Yearrs since -0.67 Yrs since quitting quitting left out of analysis Ex Smoker Ex Smoker 0.57 Exsmoker Packyears Packyears used for chronic symptoms, exsmoker status used for Lung Function models Female Height -0.68 Both are used in models Weight Height 0.62 Height is only used Exposure Exposure Cumulative 0.71 JDURADJ and Factors duration Exposure JINTADJ are tried separately in models Worked TV or movie -0.80 Both are left out of predominantly production analysis indoors over the 132 past 2 years Job Average hours INDOORS -0.64 Neither, is used in Characteristics worked/day on (Work mostly model current indoors over 2 production yrs) Average hours TV or movie 0.69 Neither is used in worked/day on production model current production Average hours THEATRE -0.73 Neither is used in worked/day on model current production Average hours CONCERT -0.61 Neither is used in worked/day on model current production Average hours Exposure 0.46 Neither is used in worked/day on duration model current production Average hours Cumulative 0.34 Cumulative worked/day on exposure exposure used current production Site TV or movie Live theatre -0.62 Both are left out of Characteristics production analysis Arcade site Playmaster job 0.95 Both are left out of title analysis Music Concert JDYWK -0.61 Both are left from Production (Average Days analysis Worked/Wk) Current Smoker Smoked in hour 0.89 Both are left from before test analysis in acute models Smoked in the # cigarettes 0.81 # cigarettes hour before test smoked during smoked during sampling period sampling period is used for acute models Current Smoker # cigarettes 0.77 # cigarettes smoked during smoked during sampling period sampling period is used for acute models 133 Atmospheric Source Smoke -0.73 Both left out of Effect Effect models Special effects % Time in 0.64 SPFX is tried in technician job Task2 some models title Self-Reported Technician 0.67 Technician- Minutes in Fog recorded reported variable Minutes in Fog used in acute models Glycol and Smolder Effect 0.62 Both variables are Mineral Oil Used by left out of acute Smoke Used Machine #2 models % Thoracic Formaldehyde 0.61 Both are left out of Concentration acute models (mg/m3) % Time Task 4 % Time Task 8 -0.61 Both variables are left out of models % Respirable % Thoracic -0.77 Used in acute fraction fraction models depending on the region within the respiratory system % Respirable % Inhalable -0.90 Used in acute fraction fraction models depending on the region within the respiratory system % Inhalable % Thoracic 0.42 Used in acute fraction fraction models depending on the region within the respiratory system Mineral Oil Atmospheric 0.72 Mineral oil tried in based theatrical Effect models smoke Mineral Oil Glycol-based -0.85 Glycol or Mineral based theatrical theatrical smoke oil tried in acute smoke models Teflon Tech Reported 0.43 Both tried in Concentration Fog Time models Personal 134 REFERENCES ACGIH. 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