“ Why the UK stalled on occupational cancer prevention, where we stand now internationally and what Scotland can do about it?” Andrew Watterson, Tommy Gorman, Rory O’Neill Occupational and Environmental Health Research Group Centre for Public Health and Population Health Research School of Health Sciences, University of Stirling, Scotland 15,764 people died from cancer in Scotland in 2013 If 10% of cancer deaths are work-related, an estimated 1576 deaths are work-related = cost to Scotland of £3,862,200,000 (estimate of £2.45 million per cancer death DEFRA 2006) Estimated 1 in 5 workers exposed to carcinogens WHO estimate that globally 7-19% of all cancers are due to toxic environmental exposures. 2009

Occupational cancer prevention? Occupational cancers Ban/ Remove carcinogens on the basis of evidence and precaution Reduce exposure to carcinogens and measure them Wear PPE Detect those exposed to carcinogens Screen workers for occupational carcinogens Treat people with occupational cancers - and use data on cases to focus on prevention strategies in the future Compensate and support those affected by occupational cancers

Hueper’s occupational cancers - some substance and Site Concerns 1942 Asbestos Benzidine Diesel Dyes, coal tar Endocrine disruptors linked to breast cancer Metal Dust Andrew Watterson UoS Holyrood March 2105 ‘Blood’ cancers Brain cancers Breast cancer (endocrine) Lung cancers Naso-pharyngeal cancers Prostate cancer (Oppenheimer 1926; Henry et al of 46 occupations Testicular cancer (Shimkin 1941 stilbestrol)

Andrew Watterson UoS Holyrood March 2105 Global estimates of fatal work-related-diseases. Hamalainen et al 2007 AJIM 50:28-41 (1) In 2012, an EU Occupational Health and Safety workshop looked at occupationally-caused and related cancers and identified ‘hidden’ groups whose occupational exposure to cancer risks and carcinogenic processes was under-represented in exposure data and intervention strategies (EASHW 2012). They noted an unrecognised work- related cancer burden in lower socio-economic classes, women, migrant workers, the precariat and floated the concept of ‘socially discriminating cancers’

Andrew Watterson UoS Holyrood March 2105 EU/Global Statistical picture. EASHW 2008 RegionNumber of all cancer deaths Attributable fraction related to work Number of deaths attributable to work Work- related cancer Cancer (total) MenWomenMen Women MenWomen Total EU 15528,953410, ,9969,038 82,034 EU 25600,508464, ,19410,144 92,338 EU 27623,709481, ,10610,177 95,581 World 3,872,7663,062,0089.6% 665,738

Table: Estimate of the proportion of cancer deaths that will be found to be attributable to various factors Best EstimateRange Tobacco Alcohol32-4 Diet Food additives<15-2 Sexual behaviour11 Yet to be discovered hormonal analogies of reproductive factors Up to Occupation42-8 Pollution21-5 Industrial products<1<1-2 Medicines and procedures Geographical factors32-4 Infective processes101-? UK/ US Cancer Pattern, cited by Peter Boyle, Source: Doll & Peto (1981)

“ Scotland and some occupational cancer studies, missed policy opportunities and developments 1875 The first case of paraffin cancer in GB was described by Bell in Scottish shale oil plants - ‘a well known fact among the local physicians’ (Hueper 1942:156) Scott described 19 cases of paraffin cancer in the Scottish industry. No effective action had apparently followed Bell’s report 1990s: Old epidemics and endemics in occupational health – cancers listed 2006 The economic costs of health service treatments for occupational cancers. Annals New York Academy Science, 1076; OEHRG OEHRG met Scottish Minister of Public Health to discuss occupational cancer prevention OEHRG held workshops and spoke at seminars on occupational cancer prevention 2008 OEHRG produced paper on ‘Burying the Evidence on occupational cancer’ 2008 OEHRG held international conference in Stirling on occupational and environmental cancer prevention 2008 OEHRG published paper in European Journal of Oncology on “occupational cancer prevention in Scotland: a missing public health priority” OEHRG worked for WHO on costs of occupational cancers 2014 APHA occupational breast cancer prevention policy initiative based on OEHRG Major public health threats in Scotland? Skewing risk assessment, risk reduction & risk management? (from 2006) Murders 2003 = 108 Road traffic fatalities 2004 = 306 (includes work link) Suicides 2004 = 835 Occupational cancer 2004 = 600 using 4% Doll/Peto estimates 1800 (12% Clapp estimate)

Alberta firefighters recognised diseases = 14. UK = 0? Source: Watterson 2015 The ‘top’ 10 occupational carcinogens and their related cancers and their prescribed industrial disease status (HSE 2012 and DWP): Substance and related Cancers Related cancers Prescribed industrial disease status Asbestos Mesothelioma Lung Larynx Stomach Yes No – rejected in 2008 No SilicaLungYes Shift workBreastNo WeldingLungNo Painting Lung Bladder No Diesel exhaust emissions Lung Bladder No Solar radiation Non melanoma skin cancer No Polycyclic aromatic hydrocarbons (PAHs) – coal tar and pitches Non melanoma skin cancer Yes Tetrachlorethylene Cervix, Non-Hodgkins Lymphoma Oesophagus No RadonLungNo

Simple solutions? The law on workplace carcinogens COSHH and related EU Management directives REACH EU Carcinogen Directive 2004 protect “workers against risks to their health and safety, including the prevention of such risks, arising or likely to arise from exposure to carcinogens or mutagens at work” (Art. 1). ECHA IARC Specific regulations such as: – Control of Asbestos Regulations Ionising Radiations Regulations 1999 [1] (IRR99) and The Radiation (Emergency Preparedness and Public Information) Regulations 2001[2] (REPPIR) CLP Regulations Hazard category – carcinogen is a substance or mixture that induces or increases cancer incidence with mechanisms relevant to humans 1A known human carcinogen – largely human evidence H350 eg-i 1B presumed human carcinogen – largely animal evidence H Suspect human carcinogen – evidence but not yet sufficiently strong CMR,toxicity, respiratory sensitiser

Global activity on cancer prevention French substitution programme 2000s WHO/IARC and Asturias 2011 PP information -regulation, enforcement and sunsetting Canada 2000s USA 1990s onwards The UK?

Scottish specific strategies and opportunities – a more Nordic model? Scottish Government discussion/ focus, with cross-party initiatives, on occupational and environmental diseases including cancer and using public and community engagement Prevention through public health and social and environmental justice - linking NHS policy, plans and practice with enforcement and regulation by HSE and SEPA and in the Scottish Government’s Better Cancer Care and Action Plans (2008>) Prevention through incentives? Scottish Government benefits for enterprises that adopt toxics use reduction/sunsetting/green jobs strategies on carcinogens? Prevention through economic penalties? Scottish parliamentary action to recover costs of occupational and environmental diseases, including occupational cancer, from employers? Greater governmental support for victims of occupational cancer through better disease recognition and recording, welfare rights and social services. ? Greater support, advice, information and use of existing regulation and enforcement where needed from HSE/SEPA/EHOs on occupational and environmental monitoring of industries and workplaces using and emitting carcinogens. ? UK ACTS and WATCH vanishing? Andrew Watterson UoS Holyrood March 2105

Reductions TURI ( ) Andrew Watterson UoS Holyrood March 2105