causal factors, with varying degrees of support from epidemiologic data. High demands and low decision latitude (job strain) in the psychosocial work environment
is associated with an increased risk of myocardial infarction (MI),9 which might be an explanation for the
excess risk noted among professional drivers. Motor exhaust exposure has been proposed as a possible risk factor
for myocardial infarction.10 The literature on myocardial
infarction among professional drivers has been reviewed
by Belkic et al.11,12
The Stockholm heart epidemiology program
(SHEEP) is a community-based case-control study of
causes of myocardial infarction (first event) among men
and women in Stockholm County. The studys objective
is to evaluate the following risk factors: chemical, physical and psychosocial work environment factors; general
environment factors; social factors; and individual factors including tobacco-smoking and alcohol-drinking
habits.13 Previous analyses of this study showed that high
exposure to combustion products from organic material
was associated with an increased risk of myocardial infarction, but motor exhaust exposure was not associated
with risk of myocardial infarction in a consistent way.14
The aim of the present study was to investigate other
potential causes for the increased risk of myocardial
infarction among professional drivers, and to study the
risk among bus, taxi and truck drivers separately. We
333
334
Bigert et al.
EPIDEMIOLOGY
TABLE 1. Number of Cases and Controls, Response Rates, and Vital Status
Among Included Individuals, Men in Stockholm 19921993
EPIDEMIOLOGY
TABLE 2.
DRIVERS
AND
335
MYOCARDIAL INFARCTION
Taxi Drivers
Truck Drivers
Cases
Controls
Cases
Controls
Cases
Controls
Cases
Controls
(N 46) (N 31) (N 44) (N 34) (N 95) (N 84) (N 106) (N 1,482)
9
13
33
35
11
16
7
26
29
23
14
25
21
32
9
12
9
27
35
18
16
19
30
23
13
13
6
36
33
12
16
17
22
24
21
15
16
21
25
23
9
22
70
20
36
26
42
32
16
31
9
23
68
21
37
18
35
47
21
30
7
22
71
22
37
23
29
49
19
35
21
29
50
20
34
36
34
30
19
31
18
74
39
17
26
14
42
52
3
23
19
57
41
14
21
19
62
32
18
24
56
54
15
25
18
46
36
7
24
19
45
42
13
30
17
34
29
6
23
10
23
32
33
45
41
47
42
45
45
45
61
11
45
10
55
14
47
6
54
15
50
7
32
7
24
4
latitude (below 25th percentile).18 We coded socioeconomic status (in six groups) according to occupation 10
years before inclusion in the study. To keep the number
of variables in the regression model as low as possible,
these six groups were collapsed to three, based on the
group-specific adjusted relative risk for MI: low risk
(high-level employees and agricultural workers), intermediate risk (low- and middle-level employees and selfemployed) and high risk (manual workers). We used
indicator variables to represent these three groups. Age
distribution and basic characteristics of the professional
drivers are shown in Table 2.
Data Analysis
We estimated the odds ratio (OR) of developing MI,
and 95% confidence intervals (CIs), by unconditional
logistic regression. The OR in each category of driver
(bus, taxi and truck drivers) was calculated using all men
who never worked as a driver at all as unexposed. We
adjusted all analyses for the stratification factors used in
the selection of controls: age (5-year age groups), hospital catchment area (10 areas), and year of enrollment
in the study (1992 or 1993). The confounders were
introduced in the regression model in steps to evaluate
Results
The distribution of the potentially confounding factors in the various driver groups as well as among all men
in the study are presented in Table 2. Smoking was more
common among the drivers than in the general population; among the controls, 47% of the taxi drivers, 49% of
336
EPIDEMIOLOGY
Bigert et al.
Adjusted
OR
95% CI
1
1.48
1.181.85
1.94
2.80
4.23
1.272.96
2.173.60
3.125.73
1
1.02
0.77
0.66
1.06
1.26
1.62
2.18
1.43
0.661.58
0.501.20
0.401.09
0.601.88
1.051.50
1.351.94
1.612.94
1.181.74
Smoking habits
Unexposed*
Ex-smokers
Current smokers
110 gm/d
1120 gm/d
20 gm/d
Alcohol consumption
Unexposed*
110 gm/d
1130 gm/d
3150 gm/d
50 gm/d
Physical inactivity at leisure time
Overweight
Diabetes mellitus
Hypertension
Socioeconomic status
High-level employees and agricultural
workers*
Low- and middle-level employees and
self-employed
Manual workers
Job strain
1
1.28
1.041.57
1.45
1.66
1.141.83
1.132.46
* Reference category.
Grams of tobacco/day among current smokers.
Grams of alcohol/day during the exposure period.
For definition see Table 2.
the truck drivers and 32% of the bus drivers were current
smokers, compared with about 30% in the general population. Being overweight was more common in bus
drivers (52%) in particular, but also taxi (32%) and
truck drivers (36%), compared with men in the general
population (29%). Low physical activity at leisure time
was characteristic for the controls in all three driver
groups, especially for taxi drivers (62%), compared with
34% in the population. There was a tendency to lower
alcohol consumption among bus drivers compared with
other drivers and nondrivers. The exposure to high
demands and low decision latitude (job strain) was
slightly more common among drivers (bus drivers, 10%;
taxi drivers, 6%; truck drivers, 7%) than among other
men (4%).
TABLE 4. Risk of Myocardial Infarction Among Male Professional Drivers, with and Without Adjustment for Potential
Confounding Factors*
Crude
Adjusted A
Adjusted B
Adjusted C
Driver group
Cases/Controls
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
Bus drivers
Taxi drivers
Truck drivers
45/31
43/34
94/84
2.14
1.88
1.66
1.343.41
1.192.98
1.222.26
1.83
1.62
1.44
1.142.94
1.022.58
1.051.98
1.49
1.34
1.10
0.902.45
0.822.19
0.791.53
1.46
1.32
1.07
0.892.41
0.812.16
0.771.50
* Bus, taxi or truck driver at any time for at least a year during the working history compared with never driver.
Adjusted for design variables only (age group, year of selection and hospital catchment area).
Adjusted for design variables, and socioeconomic status.
Adjusted for design variables, socioeconomic status, smoking, alcohol, physical inactivity at leisure time, overweight, diabetes and hypertension.
Adjusted for design variables, socioeconomic status, smoking, alcohol, physical inactivity at leisure time, overweight, diabetes, hypertension and job strain.
EPIDEMIOLOGY
DRIVERS
AND
MYOCARDIAL INFARCTION
337
TABLE 5. Risk of Myocardial Infarction Among Male Professional Drivers Subdivided by Duration of Work as a Driver,
With and Without Adjustment for Potential Confounding Factors
Crude*
Driver Group
Bus drivers
110 years
10 years
Taxi drivers
110 years
10 years
Truck drivers
110 years
10 years
Adjusted A
Adjusted B
Cases/Controls
OR
95% CI
OR
95% CI
OR
95% CI
24/20
22/11
1.73
2.95
0.953.17
1.426.13
1.56
2.41
0.852.86
1.155.06
1.30
1.92
0.692.47
0.884.15
24/19
20/15
1.83
2.00
0.993.36
1.023.94
1.63
1.67
0.893.01
0.843.31
1.27
1.51
0.662.43
0.743.06
49/40
46/44
1.78
1.55
1.162.73
1.012.36
1.57
1.32
1.022.43
0.862.03
1.30
0.92
0.822.04
0.581.46
* Adjusted for design variables only (age group, year of selection and hospital catchment area).
Adjusted for design variables and socioeconomic status.
Adjusted for design variables, socioeconomic status, smoking, alcohol, physical inactivity at leisure time, overweight, diabetes and hypertension.
Discussion
The present study showed a high risk of MI among
male professional drivers in Stockholm 19921993. The
risk excess was most pronounced among bus and taxi
drivers, both with and without adjustment for individual
TABLE 6. Risk of Myocardial Infarction Among Male Professional Drivers Subdivided by Number of Years Since Having
Stopped Working as a Driver, With and Without Adjustment for Potential Confounding Factors
Crude*
Driver Group
Bus drivers
20 years
220 years
Current drivers
Taxi drivers
20 years
220 years
Current drivers
Truck drivers
20 years
220 years
Current drivers
Adjusted A
Adjusted B
Cases/Controls
OR
95% CI
OR
95% CI
OR
95% CI
14/12
22/9
10/10
1.70
3.64
1.41
0.783.71
1.677.96
0.583.41
1.54
3.08
1.18
0.713.38
1.406.78
0.482.88
1.15
2.49
1.15
0.512.61
1.085.73
0.452.91
14/13
10/12
20/9
1.53
1.23
3.38
0.713.28
0.532.86
1.537.48
1.39
1.00
2.92
0.653.00
0.432.35
1.326.49
1.11
1.00
2.17
0.482.54
0.412.41
0.964.94
37/40
40/27
18/17
1.36
2.17
1.54
0.862.15
1.323.57
0.793.01
1.22
1.85
1.31
0.771.93
1.123.06
0.672.57
1.05
1.29
0.88
0.651.69
0.762.20
0.431.82
* Adjusted for design variables only (age group, year of selection and hospital catchment area).
Adjusted for design variables and socioeconomic status.
Adjusted for design variables, socioeconomic status, smoking, alcohol, physical inactivity at leisure time, overweight, diabetes and hypertension.
Still working as a driver or stopped working as a driver less than 2 years ago.
338
Bigert et al.
EPIDEMIOLOGY
EPIDEMIOLOGY
pital admission ratios for diseases of the circulatory system were higher among professional drivers than in the
male working population and were higher for drivers of
passenger transport than for drivers of goods vehicles.24
In both driver group comparisons, the standardized hospital admission ratio for acute MI increased with time.
In conclusion, an excess risk of MI was found among
male professional drivers in Stockholm County in 1992
1993. Adjustment for unfavorable life-style factors and
social factors reduced the odds ratios, although bus and taxi
drivers, but not truck drivers, still tended to have an increased risk. An exposure-response pattern (in terms of
duration of work) was found for bus and taxi drivers. Job
strain assessed according to the demand/control model
seemed to explain only a small part of the increased risk
among bus and taxi drivers. Previous analyses of this study
indicated that motor exhaust exposure was not associated
with risk of MI.14 It seems possible that factors in the work
environment for urban bus and taxi drivers contribute to
their increased risk of MI, but among truck drivers individual risk factors seem to explain most part of the elevated
risk. Further investigations of the psychological demands in
various driver groups are warranted, especially if the transportation of passengers is more stressful than the transportation of goods.
Acknowledgments
We thank Anders Ahlbom for coordinating the SHEEP study, Annika Gustavsson and Irene Samuelsson for management of data collection and databases, and
the physicians and nurses at the medical departments for identifying and enrolling cases and performing health examinations.
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