Smokeless tobacco and dual use among firefighters in the central United States

Association between Cardiovascular Disease Risk Factors and Cardiorespiratory Fitness in Firefighters: A Systematic Review and Meta-Analysis

Approximately 45% of on-duty related mortalities were due to sudden cardiac death, with many of these fatalities related to cardiovascular disease and overexertion, while performing emergency duties. Therefore, the aim of this systematic review was to determine the association between cardiovascular disease risk factors and cardiorespiratory fitness in firefighters. A literature search of PubMed, SCOPUS, Web of Science, Embase, EBSCOHost, and ScienceDirect was conducted; the Rayyan® intelligent systematic review tool was used to screen and select studies for inclusion. The appraisal tool for cross-sectional studies and the Critical Appraisal Skills Programme toolkit were used for methodological assessment of included studies. Data were analyzed using the Review Manager 5.3 and MedCalc® statistical softwares to determine the effects of obesity (Z = 10.29, p < 0.001) and aging (Z = 4.72, p < 0.001) on cardiorespiratory fitness. Furthermore, there was a significant effect for cardiorespiratory fitness level on systolic blood pressure (Z = 5.94, p < 0.001), diastolic blood pressure (Z = 2.45, p < 0.001), total cholesterol levels (Z = 3.80, p < 0.001), low-density lipoprotein cholesterol (Z = 4.44, p < 0.001), triglycerides (Z = 3.76, p < 0.001) and blood glucose concentration (Z = 4.78, p < 0.001). Cardiovascular disease risk factors and cardiorespiratory fitness were significantly and inversely associated in firefighters. Fire service departments should adopt behavioral intervention strategies to maintain optimum cardiovascular disease risk factor profiles and cardiorespiratory fitness among firefighters to ensure their occupational well-being.

Diversity, Equity, and Inclusion in the United States Emergency Medical Services Workforce: A Scoping Review

OBJECTIVE

Emergency medical services (EMS) workforce demographics in the United States do not reflect the diversity of the population served. Despite some efforts by professional organizations to create a more representative workforce, little has changed in the last decade. This scoping review aims to summarize existing literature on the demographic composition, recruitment, retention, and workplace experience of underrepresented groups within EMS.

METHODS

Peer-reviewed studies were obtained from a search of PubMed, CINAHL, Web of Science, ProQuest Thesis and Dissertations, and non-peer-reviewed ("gray") literature from 1960 to present. Abstracts and included full-text articles were screened by two independent reviewers trained on inclusion/exclusion criteria. Studies were included if they pertained to the demographics, training, hiring, retention, promotion, compensation, or workplace experience of underrepresented groups in United States EMS by race, ethnicity, sexual orientation, or gender. Studies of non-EMS fire department activities were excluded. Disputes were resolved by two authors. A single reviewer screened the gray literature. Data extraction was performed using a standardized electronic form. Results were summarized qualitatively.

RESULTS

We identified 87 relevant full-text articles from the peer-reviewed literature and 250 items of gray literature. Primary themes emerging from peer-reviewed literature included workplace experience (n = 48), demographics (n = 12), workforce entry and exit (n = 8), education and testing (n = 7), compensation and benefits (n = 5), and leadership, mentorship, and promotion (n = 4). Most articles focused on sex/gender comparisons (65/87, 75%), followed by race/ethnicity comparisons (42/87, 48%). Few articles examined sexual orientation (3/87, 3%). One study focused on telecommunicators and three included EMS physicians. Most studies (n = 60, 69%) were published in the last decade. In the gray literature, media articles (216/250, 86%) demonstrated significant industry discourse surrounding these primary themes.

CONCLUSIONS

Existing EMS workforce research demonstrates continued underrepresentation of women and non-White personnel. Additionally, these studies raise concerns for pervasive negative workplace experiences including sexual harassment and factors that negatively affect recruitment and retention, including bias in candidate testing, a gender pay gap, and unequal promotion opportunities. Additional research is needed to elucidate recruitment and retention program efficacy, the demographic composition of EMS leadership, and the prevalence of racial harassment and discrimination in this workforce.

Relationship Between Physical Activity, Coronary Artery Disease Risk Factors and Musculoskeletal Injuries in the City of Cape Town Fire and Rescue Service

Musculoskeletal injuries in firefighters are a common occurrence, that increase as firefighters age, and may be related to the firefighters’ physical activity habits outside of the job. Certain CAD risk factors, such as obesity, cigarette smoking and ageing may be linked to increased injury risk in firefighters. Although firefighters may meet the recommended minimum physical activity minutes, they may remain at risk for sustaining musculoskeletal injuries. Therefore, this study aims to determine the relationship between physical activity and CAD risk factors, between CAD risk factors and musculoskeletal injuries and between physical activity and musculoskeletal injuries. A total of 124 full-time firefighters, males and females, were conveniently recruited from the City of Cape Town Fire and Rescue Service. A researcher-generated questionnaire was used to collect injury, CAD risk factor and physical activity data. The proportion of firefighters who participated in leisure-time physical activity (LTPA) was 63.7%, and those who were physically inactive was 69.4%. The prevalence musculoskeletal injuries among all firefighters was 27.4%. The most prevalent musculoskeletal injury was shoulder injuries in 35.3% of firefighters, followed by multiple injuries in 26.5% and back injuries in 14.7%. Age was a significant predictor of physical inactivity in firefighters [P = .002, OR = 1.08], BMI was a significant predictor of physical inactivity [P = .050, OR = 1.08], cigarette smoking was a significant predictor of firefighters not exercising [P = .007, OR = 2.31] and the total amount of vigorous-intensity exercise was a significant predictor of musculoskeletal injuries [P = .050, OR = 1.00]. In conclusion, older firefighters were more physically inactive and had a higher prevalence of musculoskeletal injuries, and the latter decreased significantly after the age of 50 years. Emphasis should be placed on firefighters exercising in their leisure-time, especially as they aged.

Trends of cigarette smoking and smokeless tobacco use among US firefighters and law enforcement personnel, 1992-2019

BACKGROUND

Previous studies indicate tobacco use was more prevalent among firefighters and law enforcement personnel than in the US adult population. Trends of smoking and smokeless tobacco (SLT) use among these first responders are unknown. We examined trends in current smoking and SLT use among US firefighters and law enforcement personnel and compared smoking and SLT use prevalence in firefighters and law enforcement personnel to US adults in non-first-responder occupations.

METHODS

Trends of smoking and SLT use prevalence among firefighters, law enforcement personnel, and adults in other occupations were assessed by fitting joinpoint regression models using the 1992-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS). We used multivariable logistic regression models adjusted for demographics to examine associations between occupation and smoking and SLT use status using the 2018-2019 TUS-CPS data. Analyses were conducted in 2021.

RESULTS

From 1992 to 2019, the smoking prevalence declined overall (all p's < 0.01). Though SLT use prevalence among adults in non-first-responder occupations declined (annual percentage change [APC] = -1.2%; 95% confidence interval [CI] = -1.7% to -0.7%), no changes were shown among firefighters and law enforcement personnel which suggests SLT use may be increasing among firefighters over time. In 2018-2019, firefighters (adjusted odds ratio [AOR] = 3.4; 95% CI = 1.7 to 6.8) and law enforcement personnel (AOR = 3.2; 95% CI = 2.1 to 4.7) were more likely than adults in non-first-responder occupations to use SLT.

CONCLUSIONS

While smoking prevalence declined overall, SLT use is higher among firefighters and law enforcement personnel and may be increasing over time among firefighters. Research should examine reasons for SLT use by first responders. Comprehensive tobacco policies and SLT-specific cessation programs are needed for first responders.

Relationship Between Various Coronary Artery Disease Risk Factors in Firefighters

OBJECTIVE

To determine the correlation between the various coronary artery disease risk factors in firefighters.

METHODS

The study used a quantitative, cross-sectional, and correlational study design. A total of 124 full-time firefighters were conveniently recruited to participate. Research procedures were based on the ACSM guidelines.

RESULTS

Significances were found between age and body mass index (BMI) (r = 0.42, P < 0.001), age and waist circumference (WC) (r = 0.52, P < 0.001), BMI and WC (r = 0.88, P < 0.001), BMI and diastolic blood pressure (DBP) (r = 0.48, P < 0.001), between WC and DBP (r = 0.48, P < 0.001) and between gender and cigarette smoking (χ2[1] = 5.66, P = 0.017).

CONCLUSION

There were significant strong relationships between BMI, SBP, DBP, dyslipidemia, and increasing age, especially in male firefighters. Reducing key risk factors should be emphasized.

A qualitative study to assess perceptions, barriers, and motivators supporting smokeless tobacco cessation in the US fire service

While firefighters currently have low smoking rates, rates of smokeless tobacco (SLT) use among this population are remarkably high and substantially greater than similar occupational groups, and the general population. This study explored determinants associated with SLT use, barriers to cessation, and motivators for SLT cessation in the fire service. Key informant interviews were conducted in 23 career firefighters who were current (n = 14) and former (n = 9) SLT users from across the U.S. Discussions were recorded and independently coded according to questions and themes. Major themes that developed among firefighters regarding SLT use determinants included positive perceptions of SLT products, social influences from their peers and family members, acceptability of SLT use in the fire service, and a coping resource for job stress. Firefighters discussed several barriers to SLT cessation, including intrapersonal barriers such as SLT use habits and its dependency, concerns about withdrawal symptoms; and social-environmental barriers including lack of support from health and other services providers, and lack of enforcement of existing tobacco policies regarding SLT use. Firefighters also mentioned both internal and external motivators for cessation. Internal motivators included self-motivation and their health concerns while external motivators included friends and family support, incentives or rewards, and price of SLT products. Findings provide unique perspectives from firefighters on factors that influence SLT use and barriers and motivators to SLT cessation. These are insufficiently assessed and considered by the fire service organizations and their health care providers. Thus, the organizations must understand these issues in order to mitigate barriers and motivate the personnel to quit using SLT. Information gained from firefighters who were current and former SLT users can be used to develop an effective, culturally-tailored intervention that is acceptable to fire service personnel.

Development and beta test of a smokeless tobacco cessation program for firefighters

INTRODUCTION

The prevalence of smokeless tobacco (SLT) use among firefighters is substantially higher than the general population and similar occupational groups. Despite the significant health risks associated with SLT and its impact on occupational readiness, there are no occupationally-tailored SLT education or treatment programs for the fire service. The purpose of this study was to beta test QUIT SPIT!, a self-help SLT cessation program that is culturally tailored for the US fire service and firefighters who are interested in quitting.

METHODS

After development and tailoring the QUIT SPIT! SLT cessation program for firefighters, the feasibility and acceptability of the program were evaluated in a sample of eleven SLT-using firefighters who wanted to quit. The primary outcome was a 7-day point prevalence of SLT abstinence measured at 4 and 12 weeks post-enrollment follow-up assessments.

RESULTS

Four firefighters reported having quit SLT (7-days point prevalence) at follow-up at 12 weeks. Those who did not achieve SLT abstinence reported reductions in frequency and quantity in SLT use and demonstrated a decrease in nicotine dependence. Firefighters also reported being satisfied with the QUIT SPIT! cessation program.

CONCLUSIONS

The results provide strong support for the feasibility and acceptability of the QUIT SPIT! in SLT-using firefighters interested in quitting. The findings provide critical information about the next steps for further development and evaluation of the QUIT SPIT! program.

Cancer Perceptions Among Smokeless Tobacco Users: A Qualitative Study of US Firefighters

Background

Prevalence rates of smokeless tobacco (SLT) use among firefighters are remarkably high and substantially higher than similar occupational groups and the general U.S. population. The purpose of this study was to explore the perspectives of fire service personnel regarding cancer and its associations with tobacco and SLT use.

Methods

This descriptive study used a qualitative approach. Key informant interviews were conducted in 39 career firefighters and fire service administration from across the U.S. Discussion were recorded, transcribed verbatim and transferred to NVivo software for narrative analysis. Topics explored included cancer perceptions, attitudes and beliefs, and cultural factors related to SLT use behaviors. Results: Major themes that emerged among fire service personnel included concerns about cancer and its risk factors including firefighting tasks, such as fire overhaul operations, and from their lifestyle behaviors, such as alcohol and tobacco use. Firefighters also suggested a number of reasons for their increased SLT use, such as fire department tobacco-free policy and fire service culture.

Conclusion

The current study provides a rich foundation for future research, prevention, and intervention efforts for the fire service and research communities regarding tobacco and SLT use and cancer risk. Additional research on firefighters' cancer beliefs deserves future research in order to improve messaging about the risks of cancer due to firefighting.

Tobacco Use among Women Firefighters

OBJECTIVES

Firefighters play a crucial role in protecting the lives and property of the communities they serve. Health and readiness for duty among women firefighters is of great concern because they are a significantly understudied group in this critical occupation. A tobacco-free fire service has been strongly promoted, but there are no published data on the extent and types of tobacco use among women firefighters.

METHODS

Data were collected as part of a national online study of the health of women in the fire service.

RESULTS

A total of 1,712 women firefighters completed questions regarding tobacco use. Unadjusted smoking and smokeless tobacco rates were 5.1% and 1.2%, respectively. Age standardized smoking rates were lower than those of male firefighters and U.S. adult women. Smokeless tobacco use prevalence was very low compared with male firefighters, but comparable with U.S. adult women. Tobacco users were more likely to have lower education and income and were younger when compared with those who did not use tobacco. There was a strong association between tobacco use and problem and binge drinking.

CONCLUSIONS

Current findings suggest that the rates of cigarette and smokeless tobacco use are relatively low among women firefighters. Unhealthy lifestyle behaviors such as problem and binge drinking were strongly associated with tobacco use.

The Prevalence and Health Impacts of Frequent Work Discrimination and Harassment among Women Firefighters in the US Fire Service

INTRO

Both discrimination and harassment directly impact mental and physical health. Further, workplace discrimination degrades workplace culture and negatively impacts health behaviors, job-related outcomes, and family dynamics. Women represent a small proportion of the fire service and are often the targets of discrimination/harassment, yet little research documents the impact of such experiences. The purpose of this study was to evaluate the relationship between chronic work discrimination and/or harassment and women firefighters' (FFs) physical and mental health, substance abuse, and job efficacy, stress, and satisfaction.

METHODS

Snowball sampling was used to solicit participation from women career FFs. Participants completed an online survey regarding physical and mental health, health behavior, job efficacy/stress/satisfaction, and family well-being. Logistic regression examined the impact of work discrimination-harassment severity on dichotomous variables.

RESULTS

1,773 had complete data on their experiences with work-related discrimination and harassment. Women reported experiencing verbal (37.5%) and written (12.9%) harassment, hazing (16.9%), sexual advances (37.4%), and assaults (5.1%) in the fire service. FFs in the highest tertile of work discrimination-harassment severity reported over 40% more poor health days in the last 30 days (OR=1.42; 95%CI=1.33-1.51; p<0.001). Women who experienced moderate and severe discrimination/harassment had negative mental health outcomes including higher prevalence of depressive symptoms, anxiety, and PTSD symptoms. Those who experienced high rates of discrimination and/or harassment also were more likely to report issues with alcohol consumption.

CONCLUSION

The impact of discrimination and harassment, related negative physical and mental outcomes, low levels of job satisfaction, and negative impact of these experiences on family/home stress likely take a significant toll on women in the fire service. Findings confirm and extend previous work suggesting there is a need to improve the mental and physical health of women FFs. Future work should examine the prospective relationship between discrimination/harassment and poor health outcomes and potential policies/practices to reduce these negative behaviors.

Deployment and Smokeless Tobacco Use Among Active Duty Service Members in the U.S. Military

Introduction

The prevalence of smokeless tobacco use among U.S. active duty service members has been much higher than in the U.S. general population. The association between deployment and smokeless tobacco use has not been well studied. We investigated the association between deployment and smokeless tobacco use among U.S. active duty service members. We also evaluated the modification effects from other factors related to smokeless tobacco use on the deployment-smokeless tobacco use association.

Materials and Methods

Eligible active duty service members stationed at two military installations (Fort Bragg, NC, USA and Lackland Air Force Base, TX, USA) were recruited from July 2015 to May 2016. Each participant completed a self-administered questionnaire. Multivariable logistic regression was used to assess the association between deployment and smokeless tobacco use and estimated odds ratio (OR) and 95% confidence interval (CI). Stratified analysis was performed to evaluate modification effects from other commonly known factors related to smokeless tobacco use in military, specifically, cigarette smoking status, use among family members (family history of use), perception of harm, and use among military peers.

Results

Out of 2,465 study participants who completed the questionnaire, 548 were smokeless tobacco users. Service members who had been deployed to a combat zone had 1.39 fold (95% CI = 1.03–1.87) increased odds of using smokeless tobacco than those who never deployed to a combat zone. The odds of smokeless tobacco use among those who had been deployed once, twice, three times and four or more times to a combat zone were 1.27 (95% CI = 0.91–1.78), 1.30 (95% CI = 0.85–1.99), 2.49 (95% CI = 1.45–4.28), and 2.88 (95% CI = 1.71–4.86), respectively, with a significant dose–response trend (p for trend &lt;0.0001). Further, subjects who served in combat units during deployment exhibited more than two-fold increased odds of use as compared with those who had never been deployed (OR = 2.03, 95% CI = 1.41–2.93). In stratified analysis, the association between deployment and smokeless tobacco use was only present among subjects who never smoked cigarettes, those without family history of smokeless tobacco use, and those who had low perception of harm of use.

Conclusions

Military deployment was associated with smokeless tobacco use among active service members. However, the influence of military deployment on smokeless tobacco use was not equally strong on all service members. Subjects who never smoked cigarettes, who had no family history of use and who had low perception of harm were the most susceptible subgroups to deployment-related smokeless tobacco use. This study has implications to identify high-risk subgroups to reduce smokeless tobacco use in the U.S. military.

Prevalence and Correlates of Late Initiation of Smokeless Tobacco in US Firefighters

Introduction

Prevalence rates of smokeless tobacco (SLT) use and late initiation among firefighters (ie, starting use as an adult after joining the fire service) are remarkably high, 10.5% and 26.0%, respectively. The purpose of this study is to examine characteristics associated with late SLT initiation in a sample comprised of male career firefighters from two large cohort studies.

Methods

We examined correlates of late SLT initiation in a secondary analysis of data combining the baseline evaluations of two published firefighter health studies with 1474 male career firefighters in the United States.

Results

Fourteen percent of participants were current SLT users. Among this group, the unadjusted rate of firefighters who initiated SLT use after joining the fire service was 15.9%, while the age-standardized rate was 38.2%; this is substantially higher than the national adjusted late initiation rate among adult males (0.8%). In addition, firefighters demonstrated higher rates of late SLT initiation (15.9% unadjusted; 18.4% age-standardized) when compared to males in the military overall (13.8%).

Conclusions

The exceptionally high prevalence of SLT use overall and late initiation in the fire service suggest that joining the fire service in the United States is a risk factor for SLT use. There is a need to develop interventions aimed at reducing SLT use in the fire service that are specifically tailored for this occupational group.

Implications

The high prevalence of late SLT initiation (ie, starting use as an adult after joining the fire service) among firefighters should be addressed by both researchers and fire service organizations given the significant health risks associated with SLT and its impact on occupational readiness. There is a need for developing intervention programs aimed at reducing SLT use in the fire service. Interventions would need to be specifically tailored for this occupational group and their unique culture, given that joining the fire service appears to be a risk factor for SLT initiation among firefighters who did not use tobacco prior to joining the fire service.

Alcohol Use and Problem Drinking among Women Firefighters

OBJECTIVES

Given high levels of occupational stress and toxic exposures, firefighters have a relatively high prevalence of occupationally related medical and mental health disorders compared with the general public. Previous research found high rates of heavy and binge drinking among male firefighters. This study is the first to examine alcohol use among women firefighters.

METHODS

Data were collected as part of a national online survey of women, career firefighters.

RESULTS

A total of 1,913 women firefighters completed questions regarding alcohol use. Nearly 40% reported binge drinking in the previous month and 4.3% reported driving while intoxicated. Among those who drank, 16.5% screened positive for problem drinking. Problem drinkers were more than 2.5 times as likely to have been diagnosed with depression or have symptoms of posttraumatic stress disorder, and were approximately 40% more likely to have been injured on the job in the previous year, when compared with other women firefighters. Those who screened positive for problem drinking also were significantly less likely to say that they would recommend a fire service career to other women.

CONCLUSIONS

As with male firefighters, heavy and problem drinking are prevalent among women firefighters and are associated with negative occupational outcomes.

Tobacco use pattern among a national firefighter cohort

INTRODUCTION

To date, there have been no large-scale, national epidemiological studies of tobacco use patterns among firefighters, particularly with a focus on smokeless tobacco (SLT) and dual use with cigarettes. While rates of firefighters' smoking are relatively low compared to the general population, SLT use typically is substantially higher than the populations they protect. In the current study, we systemically examine tobacco use, including SLT and dual use, and the health-related profiles of various tobacco use groups in a national sample of career firefighters.

METHODS

Data are from a national cohort study of career departments (N = 20) comprised of 947 male firefighters.

RESULTS

Among 947 participants, 197 (21%) were tobacco users, of which, 34.5% used cigarettes, 53.2% used SLT, and 12.2% used both cigarettes and SLT. Adjusted rates of smoking, SLT use, and dual use were 13.2%, 10.5%, and 12.2%, respectively. Tobacco users of all types were significantly younger and had served fewer years in fire service and were significantly more likely to engage in heavy and binge drinking, as well as more likely to show signs of depressive symptoms compared to nontobacco users.

CONCLUSIONS

Detailed information on tobacco use pattern will aid in better understanding what factors are contributing to the high rates of SLT and dual use among firefighters in order to guide and develop an appropriate treatment program for the fire service.

Adiposity predicts self-reported frequency of poor health days among male firefighters

OBJECTIVE

Quantify the association between adiposity and frequency of self-reported poor health days among male firefighters.

METHODS

Measures were taken for body mass index, waist circumference, and percentage of body fat. Firefighters self-reported the outcome of the number of poor health days in the past 30 days. Zero-inflated negative binomial models and fractional polynomial plots were used to determine the impact of adiposity on the frequency of self-reported poor health days.

RESULTS

Body mass index (rate ratio [RR]: 1.037; 95% confidence interval [CI]: 1.003 to 1.073), waist circumference (RR: 1.012; 95% CI: 0.999 to 1.030), and percentage of body fat (RR: 1.021; 95% CI: 0.999 to 1.041) were associated with self-reported poor health days.

CONCLUSIONS

Adiposity is positively associated with frequency of self-reported poor health days among male firefighters. Future efforts to improve health among firefighters should emphasize reductions in adiposity.

An examination of the benefits of health promotion programs for the national fire service

BACKGROUND

Firefighters suffer from high prevalence of obesity, substandard fitness, and cardiovascular-related deaths. There have been a limited number of firefighter health promotion programs that have been developed and empirically-tested for this important occupational group. We evaluated the health of firefighters from departments with well-developed health promotion programs and compared them with those from departments not having such programs using a large national sample of career fire departments that varied in size and mission. We measured a broad array of important individual firefighter health outcomes (e.g., body composition, physical activity, and general and behavioral health) consistent with national fire service goals and addressed significant statistical limitations unaccounted for in previous studies.

METHODS

Using the approach of purposive sampling of heterogeneous instances, we selected and conducted a national evaluation of 10 departments already implementing wellness and fitness programs (Wellness Approach; WA) with 10 departments that did not (Standard). Participants were 1,002 male firefighters (WA n = 522; Standard n = 480) who underwent assessments including body composition, fitness, and general/behavioral health (e.g., injury, depressive symptoms).

RESULTS

Firefighters in WA departments were healthier than their Standard department counterparts. For example, they were less likely to be obese (adjusted [A]OR = 0.58; 95% CI = 0.41-0.82), more likely to meet endurance capacity standards for firefighting (AOR = 5.19; 95% CI = 2.49-10.83) and have higher estimated VO2max (40.7 ± 0.6 vs. 37.5 ± 1.3 for firefighters in Standard departments; p = 0.001). In addition, WA firefighter were substantially less likely to smoke (AOR = 0.30; 95% CI = 0.17-0.54) or ever have been diagnosed with an anxiety disorder (AOR = 0.27; 95% CI = 0.14-0.52) and they expressed higher job satisfaction across several domains. However, WA firefighters were somewhat more likely to have reported an injury to Workers' Compensation (AOR = 1.74; 95% CI = 1.05-2.90). It was notable that both groups evidenced high prevalence of smokeless tobacco use and binge drinking.

CONCLUSIONS

Firefighters in departments selected based on having strong wellness programs (WA) were healthier along a number of dimensions important to firefighter wellness and operational readiness. However, several health areas require greater attention including problematic alcohol consumption and smokeless tobacco use, suggesting that more emphasis on these behavioral health issues is needed in the fire service.