Saf Health Work.  2012 Jun;3(2):110-116.

When Work is Related to Disease, What Establishes Evidence for a Causal Relation?

  • 1Finnish Institute of Occupational Health, Cochrane Occupational Safety and Health Review Group, Kuopio, Finland.
  • 2Coronel Institute of Occupational Health, Academic Medical Center, Amsterdam, the Netherlands.


Establishing a causal relationship between factors at work and disease is difficult for occupational physicians and researchers. This paper seeks to provide arguments for the judgement of evidence of causality in observational studies that relate work factors to disease. I derived criteria for the judgement of evidence of causality from the following sources: the criteria list of Hill, the approach by Rothman, the methods used by International Agency for Research on Cancer (IARC), and methods used by epidemiologists. The criteria are applied to two cases of putative occupational diseases; breast cancer caused by shift work and aerotoxic syndrome. Only three of the Hill criteria can be applied to an actual study. Rothman stresses the importance of confounding and alternative explanations than the putative cause. IARC closely follows Hill, but they also incorporate other than epidemiological evidence. Applied to shift work and breast cancer, these results have found moderate evidence for a causal relationship, but applied to the aerotoxic syndrome, there is an absence of evidence of causality. There are no ready to use algorithms for judgement of evidence of causality. Criteria from different sources lead to similar results and can make a conclusion of causality more or less likely.


Causality; Occupational medicine; Occupational diseases; Epidemiological studies
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