Myocardial Infarction Among Professional Drivers

Carolina Bigert,1,2 Per Gustavsson,1,2 Johan Hallqvist,3 Christer Hogstedt,1,4

Marie Lewn,1,2 Nils Plato,1,2 Christina Reuterwall,5 and Patrik Schele1,2
Background. Professional drivers are at an increased risk of
myocardial infarction but the underlying causes for this increased risk are uncertain.
Methods. We identified all first events of myocardial infarction among men age 4570 years in Stockholm County for
1992 and 1993. We selected controls randomly from the population. Response rates of 72% and 71% resulted in 1067 cases
and 1482 controls, respectively. We obtained exposure information from questionnaires. We calculated odds ratios (ORs),
with and without adjustment for socioeconomic status, tobacco
smoking, alcohol drinking, physical inactivity at leisure time,
overweight status, diabetes and hypertension.
Results. The crude OR among bus drivers was 2.14 (95%

confidence interval 1.34 3.41), among taxi drivers 1.88

(1.19 2.98) and among truck drivers 1.66 (1.222.26). Adjustment for potential confounders gave lower ORs: 1.49
(0.90 2.45), 1.34 (0.822.19) and 1.10 (0.79 1.53), respectively. Additional adjustment for job strain lowered the ORs
only slightly. An exposure-response pattern (by duration of
work) was found for bus and taxi drivers.
Conclusions. The high risk among bus and taxi drivers was
partly explained by unfavorable life-style factors and social
factors. The work environment may contribute to their increased risk. Among truck drivers, individual risk factors
seemed to explain most of the elevated risk.
(EPIDEMIOLOGY 2003;14:333339)

Key words: occupational diseases, myocardial infarction, occupational exposure.

n increased risk of coronary heart disease has

been reported in a large number of studies of
professional drivers,1 8 especially among bus
drivers. Unfavorable life-style habits, chemical or psychosocial factors in the work environment, or a combination of several risk factors have been suggested as
From the 1Department of Occupational and Environmental Health, Stockholm
Center of Public Health; 2Division of Occupational Medicine and 3Division of
Social Medicine, Department of Public Health Sciences, Karolinska Institutet,
Stockholm; 4National Institute for Working Life, Solna; and 5Department of
Epidemiology, Stockholm Center of Public Health, Stockholm, Sweden.
Address correspondence to: Carolina Bigert, Department of Occupational and
Environmental Health, Norrbacka, Karolinska Hospital, SE-171 76 Stockholm,
Sweden; carolina.bigert@smd.sll.se
The study was supported by the Swedish Council for Work Life Research (Grant
93 0541).
The SHEEP Study Group: Institute of Environmental Medicine, Department of
Public Health Sciences, Units of Social Medicine and Occupational Health, and
Department of Medical Epidemiology, Karolinska Institutet; National Institute
for Working Life, Department of Occupational Health; National Institute for
Psychosocial Factors and Health; Departments of Environmental Medicine,
Epidemiology, Occupational Health, and Social Medicine, Stockholm Center of
Public Health; the Departments of Medicine at Danderyd, Huddinge, Lwenstrmska, Nacka, Norrtlje, Sabbatsberg, St Grans, Sdersjukhuset, and
Sdertlje Hospital, and the Departments of Cardiovascular Medicine and Clinical Chemistry, Karolinska Hospital (all at hospitals in the County of Stockholm,
Sweden).
Submitted 26 June 2001; final version accepted 7 January 2003.
Copyright 2003 by Lippincott Williams & Wilkins, Inc.

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

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Bigert et al.

EPIDEMIOLOGY

TABLE 1. Number of Cases and Controls, Response Rates, and Vital Status
Among Included Individuals, Men in Stockholm 19921993

May 2003, Vol. 14 No. 3

ronment, social factors and personal

life-style factors, as well as a lifetime
occupational history including occuCases
Controls
pation, work tasks and company name
No.
(%)
No.
(%)
and address for all jobs held for at least
Identified from study base
1,485
100
2,088
100
1 year. We also invited nonfatal cases
Responding to questionnaire
1,202
81
1,538
74
and a similar proportion of controls to
Sufficient data for coding of occupational
1,067
72
1,482
71
history and confounders*
a health examination at 3 months afVital status of included individuals (percentages
ter either the onset of disease (cases)
among included individuals)
Nonfatal
919
86
1,482
100
or inclusion (controls). The examinaFatal
148
14
0
tion included blood samples and re* Smoking habits, alcohol consumption, physical inactivity at leisure time, overweight, diabetes mellitus,
cording of blood pressure, height and
hypertension and socioeconomic status.
weight. Data from the questionnaire/
Exposure information obtained from next of kin.
interview and health examination were
combined, if applicable, when classifyrestricted the study to men, as there were very few
ing subjects into exposure categories. We coded occupainfarctions among the female drivers.
tions according to the Nordic version of the international
classification of occupations.16 An occupational code was
assigned to every job held for at least a year. There were
Methods
147 cases and 129 controls who had ever worked as a driver
Identification of Cases and Controls
(for at least 1 year). These included 77 bus drivers, 78 taxi
The study base comprised all Swedish citizens living
drivers and 179 truck drivers; 53 persons had worked in two
in Stockholm County age 4570 years and free of preof these categories, and 5 had worked in all three.
vious MI. Cases were men who had their first MI in 1992
We classified smoking habits from age 15 in five
or 1993. From January to October 1992 the upper age
categories: never-smokers, ex-smokers and current
limit for cases and controls was 65; this limit was exsmokers smoking 110, 1120 or 20 gm of tobacco/
tended to age 70 thereafter. Cases comprised all men
day. Persons who had stopped smoking less than 2 years
with a first-time MI, whether fatal (death within 28
before inclusion in the study were considered as current
days) or nonfatal, and diagnosed according to specified
smokers. We classified alcohol habits in five categories:
criteria using information on symptoms, ECG, enzymes
persons who never drink alcohol, and four groups acand autopsy findings.15 We identified cases from three
cording to average consumption during the period the
sources: the medical care units at the 10 emergency
person used alcohol: 110, 1130, 3150 and 50 gm of
hospitals within the Stockholm County (87% of the
alcohol/day. We coded subjects who reported no regular
cases), other hospital units (1% of the cases, obtained
exercise other than occasional walks during the last
from a computerized hospital discharge register) or death
510 years as physically inactive at leisure time. We
certificates from the Causes of Death Register at Statiscalculated body mass index (BMI) from information on
tics Sweden (12% of the cases). We selected controls
weight and height (BMI weight [kg] per height
randomly from the study base through a computerized
squared [m2]); if the BMI exceeded 27, the man was
population register, stratified for sex, 5-year age group,
classified as overweight. We coded subjects with a hishospital catchment area and year of enrollment in the
tory of drug- or diet-treated diabetes as diabetics. We
study (1992 or 1993). Detailed information about the
assessed the presence of hypertension from information
procedure for identification of cases and controls has
on the use of antihypertensive drugs, or a systolic blood
been reported elsewhere.13 The number of identified and
pressure exceeding 180 mmHg or a diastolic pressure
responding cases and controls, and vital status among
exceeding 100 mmHg at the health examination. Blood
included individuals, is presented in Table 1. The study
laboratory data were available only for the nonfatal
was approved by the ethics committee of the Karolinska
cases; because of a high proportion of missing data we
Institutet. All study subjects were included after providdid not include blood lipids in the standard set of coning informed consent.
founding variables.
We determined the average exposure to job strain
Exposure Assessment
during the last 5 years before recruitment or retirement
We collected exposure information by postal quesby summering the scores of five questions on psychologtionnaires, supplemented by a telephone interview in
ical demands at work and six questions on decision
case of incomplete answers. For fatal cases, the questionlatitude according to the Karasek-Theorell model.17 Job
naires were completed by next of kin. The questionstrain was considered present among those with both
naires covered the physical and psychosocial work envihigh demands (over 75th percentile) and a low decision

EPIDEMIOLOGY
TABLE 2.

May 2003, Vol. 14 No. 3

DRIVERS

AND

335

MYOCARDIAL INFARCTION

Characteristics of Professional Drivers and of All Men in the Study

Bus Drivers
Exposure Factor

Age group (years) (%)

4550
5155
5660
6165
6670
Smoking pattern
Never smoked (%)
Ex-smoker (%)
Current smokers (%)
Grams/day*
Duration (years)
Alcohol consumption (%)
Grams/day
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

Taxi Drivers

Truck Drivers

All Included Men

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

* Grams of tobacco/day; mean value among current smokers.

Duration of smoking (in years); mean value among current smokers.
Grams of alcohol/day; mean value during the exposure period.
No regular exercise other than occasional walks during the last 510 years.
BMI 27.
History of drug- or diet-treated diabetes.
# Use of antihypertensive drugs, or a systolic blood pressure exceeding 180 mmHg or a diastolic pressure exceeding 100 mmHg at the health examination.
** Coded according to occupation 10 years before inclusion.
Average exposure during the last 5 years before recruitment or retirement. Exposed to both high demands (over 75th percentile) and a low decision latitude (below
25th percentile). Fourteen subjects had missing data.

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

confounding from different types of exposures separately.

First, we adjusted the ORs for socioeconomic status.
Secondly, we adjusted for exposures not directly related
to the work environment, including smoking habits,
alcohol habits and physical inactivity at leisure time as
well as the medical/metabolic factors of obesity, diabetes
and hypertension. Finally, we adjusted the ORs for job
strain. We used indicator variables corresponding to the
categories described above for all exposures. We also
calculated the OR of MI among drivers subdivided by
duration of work (110 years, 10 years) and number of
years since having stopped working as a driver (current,
220 years, 20 years). The cutoff for categories of work
duration and time since having stopped driving was
based on the number of drivers, aiming at an equal
distribution among the categories.

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

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EPIDEMIOLOGY

Bigert et al.

TABLE 3. Risk of Myocardial Infarction Calculated from

Logistic Regression, Adjusted for All Potential Confounders
Listed in the Table as well as for Age Group (5 Years), Year
of Selection and Hospital Catchment Area
Exposure Factor

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

The adjusted ORs for the variables listed in Table 2

are presented in Table 3. Smoking was the strongest risk
factor for MI, followed by diabetes mellitus and overweight status, as well as job strain.
The crude OR for development of MI was more than
doubled among bus drivers, about doubled among taxi
drivers and slightly lower but still elevated among truck
drivers, as shown in Table 4. The ORs decreased somewhat after adjustment for socioeconomic group but were
still clearly elevated in all driver groups (adjusted A in
Table 4). Additional adjustment for smoking, alcohol,
physical inactivity at leisure time, overweight status,
diabetes and hypertension further lowered the ORs (adjusted B). Among bus drivers and taxi drivers there was
still a tendency to an increased risk, but among truck
drivers the OR was close to unity after this adjustment.
Including job strain in the regression model (adjusted
C) generally lowered the risks only slightly.
To further investigate the effect of job strain, we
included the job strain quotient (the ratio of the sum
score of demand to the some score of control) as a
continuous variable in the regression (data not shown).
However, this variable had no additional effect on the
risk estimates for the drivers. An extended model using
a larger set of variables to adjust for smoking (including
continuous variables for time since stopping smoking
among ex-smokers, and the average consumption of
tobacco per day among current smokers) showed no
indication of residual confounding by smoking habits.
Furthermore, there was no change in the risk estimates
for the driver groups when duration of smoking was
added to the regression model. Additional analyses with
the original six groups of socioeconomic status did not
change the results.
Analyses restricted to nonfatal cases showed that the
adjusted ORs (in a model corresponding to adjusted B
in Table 4) for MI in the various driver groups were
slightly lower for bus drivers (OR 1.38; CI 0.79
2.39) and for taxi drivers (1.24; 0.712.16), but slightly
higher for truck drivers (1.15; 0.79 1.66).
The association of MI risk among professional drivers
with work duration, used as a proxy for cumulative

1
1.28

1.041.57

1.45
1.66

1.141.83
1.132.46

May 2003, Vol. 14 No. 3

* 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

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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.

exposure, is shown in Table 5. An exposure-response

pattern was evident for bus drivers, with an almost
two-fold adjusted OR among those who had been working more than 10 years as a bus driver but only slightly
increased OR among those who had been working 1 to
10 years. A similar but less pronounced trend was
present among taxi drivers. Among truck drivers there
was no evidence of increased risk with longer exposure.
If professional driving is associated with an increased
risk of MI and the effect is reversible, then the risk would
be expected to decline after stopping working as a driver.
Table 6 shows the estimated relative risk among drivers
subdivided by number of years since having stopped
working as a driver. Among bus drivers, the risk was
highest in the intermediate class (stopped driving 220
years ago). There was no apparent excess risk among bus
drivers who currently were driving, or among those who
had stopped more than 20 years ago. Current taxi drivers
had an increased risk of developing MI, but no increased
risk was noted for taxi drivers who had stopped working
more than 2 years ago. The risk was slightly increased
among truck drivers who had stopped driving 220 years

ago, but no excess risk was noted among those who

currently were truck drivers.
Because some of the drivers had been driving more than
one vehicle, we also investigated the risk among those who
had been bus, taxi or truck drivers only. This reduced the
group sizes to 48 bus drivers, 39 taxi drivers and 138 truck
drivers, and gave slightly reduced risks in all driver groups.
A model corresponding to adjusted B in Table 4 gave
ORs of 1.43 (CI 0.76 2.67) for bus drivers, 1.21 (0.62
2.35) for taxi drivers and 0.97 (0.671.40) for truck drivers.
However, an exposure-response pattern was still evident for
bus drivers (OR 0.94 [CI 0.39 2.29] for 110 years
and 2.21 [0.875.64] for 10 years) and to a lesser extent
for taxi drivers (0.92 [0.332.59] for 110 years and 1.46
[0.613.48] for 10 years).

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.

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Bigert et al.

risk factors. Because an occupational factor such as stress

may exert its effect through mechanisms such as hypertension or metabolic changes, the adjustment for hypertension, diabetes and BMI may introduce an overadjustment if the purpose is to evaluate the influence of
occupational factors alone. Thus, both the crude risk
and the various adjusted risks should be considered when
evaluating the effect of occupational factors. An advantage with this study was that the occupational information covered the whole lifetime up to the time of
inclusion.
Low socioeconomic status is associated with an increased risk of MI,19 and adjustment for socioeconomic
status partially reduced the risks among professional
drivers. Uncontrolled and residual effects of socioeconomic status seem unlikely because socioeconomic status did not differ much among the driver groups, and
therefore can not explain the higher risk of MI among
bus and taxi drivers than among truck drivers. The
drivers smoked more than the general population, but
the excess risk of MI that was observed among bus and
taxi drivers was only partially explained by their tobacco
smoking habits. An extended regression model incorporating time since stopping smoking and smoking intensity, as well as duration of smoking, did not alter the risk
estimates, indicating that residual confounding from tobacco smoking is unlikely. Drivers were more often
overweight than the general population, but the cases
among bus drivers were less obese than the cases in
general. We have no explanation for this pattern, but
the numbers were small and so it may be a chance
finding. The proportion of drivers with diabetes and
hypertension did not differ much from the general population, although again numbers were small. Thus, the
risk remained high among bus and taxi drivers but not
among truck drivers when adjusting for socioeconomic,
life-style and metabolic risk factors. We conclude that
the increased risk of MI among bus and taxi drivers may
be explained only partially by an overrepresentation of
individuals with these risk factors.
Earlier epidemiologic studies show that stress affects
the development of coronary heart disease, and occupational stress has been suggested as an explanation for the
high cardiovascular morbidity and mortality in drivers.4,20,21 In the present study, perceived job strain was
more common among bus, taxi and truck drivers than
among other men, although the proportion of exposed
persons was small. Job strain is thought to affect the risk
of cardiovascular disease through physiologic changes
such as increases in blood pressure and blood levels of
neuroendocrine hormones (adrenaline, noradrenaline,
cortisol).20 Applying job strain at the final step in the
regression may have underestimated the effect slightly.
However, the specific mechanisms by which job strain
contributes to cardiovascular disease are still not certain.

EPIDEMIOLOGY

May 2003, Vol. 14 No. 3

Job strain in terms of demand/control explained only a

small part of the risk among bus and taxi drivers after
adjustment for the other risk factors. It is possible, however, that this way of measuring stress does not adequately reflect the aspects of job stress that are relevant
for the drivers.
The results indicate an increased risk of developing
MI among bus drivers who stayed more than 10 years in
the profession of driving. A similar but less pronounced
tendency was present among taxi drivers. This exposureresponse pattern would not emerge if the risk excess was
caused by a selection of individuals with unfavorable
life-style into the driving occupation. Among taxi drivers, there was a pronounced excess in risk only among
current drivers and drivers who had stopped working less
than 2 years ago, pointing towards an effect of a very
short duration. The reason why bus drivers who stopped
driving 220 years ago had a higher risk than the group
including current drivers is unclear. These apparently
contradictory patterns may be caused by random variation because numbers are small, but may possibly be
explained by differences in the type of employment
contract for bus and taxi drivers. Bus drivers are employees of large companies whereas taxi drivers often are
self-employed. The bus drivers working hours are fixed,
and drivers have few opportunities to adjust the job to
the health situation. MI is often preceded, sometimes for
many years, by symptoms of coronary insufficiency (angina pectoris). Bus drivers may more often have to leave
their job if they have symptoms of preliminary stages of
coronary heart disease. Taxi drivers, on the other hand,
might instead adapt their working hours to these symptoms and stay in service.
Our findings are in accordance with results from
earlier studies. In the Oslo study22 bus, taxi and tram
drivers had higher total and coronary heart disease mortality rates compared with other occupational groups;
these results were partly attributed to an unfavorable risk
factor profile. Rosengren et al.4 found an increased risk of
coronary heart disease among 103 middle-age bus and
tram drivers in Gothenburg, compared with men from
other occupational groups, with the risk being independent of standard risk factor status. After a mean of 11.8
years of follow-up, the adjusted odds ratio among bus and
tram drivers was 3.0 (CI 1.8 5.2) for incident coronary heart disease. In the same study taxi drivers tended
to have an increased risk, but no excess risk was found
among truck drivers. In Sweden, occupations in transport work, and among them professional drivers, constitute one of the occupational groups with the highest
incidence of MI.23 In a cohort study on the whole
working population of Denmark, bus drivers and taxi
drivers had excess risks of being admitted to hospital
with ischemic heart disease.7 In a recent study of professional male drivers in Denmark the standardized hos-

EPIDEMIOLOGY

May 2003, Vol. 14 No. 3

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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