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Diagnosis and Initial Management of Nonmalignant Diseases Related to Asbestos

The Ad Hoc Statement Committee submits that the American Thoracic Society currently recognizes no confounding by cigarette smoking in the radiographic presentation of asbestosis (1). This challenges the current state of science in this field. Small, irregular opacities are recognized to be present on the posteroanterior chest X-ray in a significant number of individuals ( 5%) without any prior history of exposure to either particles or fibers. There is voluminous investigation defining the capacity of cigarette smoking to result in such a profusion of irregular opacities (summarized in Reference 2). This association between cigarette smoking and chest X-ray findings of an interstitial lung injury is also supported by computed tomography that similarly demonstrates these opacities (3). Furthermore, there are pathologic data delineating the relationship between collagen deposition and fibrosis in the human lung and cigarette smoking (4). This manifests as microscopic foci of fibrosis in areas of emphysematous destruction, peribronchiolar fibrosis as an aspect of small airway disease, or the more generalized fibrosis observed with respiratory bronchiolitis–associated interstitial lung disease. Finally, there is postulated to be a shared mechanism of injury between cigarette smoking and fiber inhalation. Exposures to all particles and fibers can present as an oxidative stress in the lung and effect a fibrotic injury to the respiratory tract. Those particles associated with cigarette smoking are comparable to other particles and fibers in that oxidant generation follows in vitro and in vivo exposures (summarized in Reference 5). Such free radical production has been proposed as the common avenue for fibrosis in a tissue exposed to either cigarette smoke or asbestos.

Decades of investigation have provided the insight that cigarette smoking can confound the diagnosis of asbestosis. To disregard this evidence discredits the American Thoracic Society as a scientific body and contradicts the Society's recognition of interstitial lung disease associated with cigarette smoking (6).

Andrew J. Ghio^a and Victor L. Roggli^b

^a United States Environmental Protection Agency Chapel Hill, North Carolina
^b Duke University Medical Center Durham, North Carolina

FOOTNOTES

Conflict of Interest Statement: A.J.G. earns $10,000 annually in providing opinions to both plaintiff and defense law firms and functioning as an expert witness for both plaintiff and defense law firms; V.L.R. earns approximately $100,000 per year as an expert in asbestos litigation and this comes from both plaintiff and defense attorneys and involves numerous law firms and is about equally divided between plaintiff and defense firms.

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