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Firefighter Cancer Risk Perceptions


The fire service operates in a somewhat unique environment compared to other occupations. Public and firefighter perception can be that the greater the risk firefighters accept the safer the public will be (De Lisi, 2005; Pessemier, 2008).  This idea can somewhat be seen in fire service tradition and culture. Many fire service traditions are very old and have experienced little change because the fire service tends to be extremely resistant to change (De Lisi, 2005).

The fire service faces many challenges while completing their mission of public safety but the most newly discovered challenge is firefighter cancer. Firefighters are being diagnosed with and dying from cancer at higher rates than the general public (Daniels et al., 2014; LeMasters et al., 2006; Pukkala et al., 2014). This alarming, newly discovered epidemic was brought to light in three major scientific studies. In the earliest study LeMasters et al. (2006) conducted a meta-analysis of 32 smaller studies examining 20 different types of cancers. The study found that firefighters were more prone to be diagnosed with 10 types of cancers over general public. The second study conducted by the National Institute for Occupational Safety and Health (NIOSH) found that overall firefighters have a 14% higher cancer morbidity rate than the general public had. This study examined 29,993 career fire fighters from San Francisco, Chicago, and Philadelphia from 1950- 2009 (Daniels et al., 2014). Lastly, Pukkala et al. (2014) conducted a study of over 16,000 firefighters in five Nordic countries which found similar results to the NIOSH study which are listed in. The results of these studies are detailed in Table 1.

Table 1)

Meta-analysis Results (LeMasters et al., 2006)
Testicular cancer (102% higher risk) Multiple myeloma (53% higher risk)
Non‐Hodgkin lymphoma (51% higher risk) Skin cancer (39% higher risk)
Brain cancer (32% higher risk) Malignant melanoma (32% higher risk)
Rectum (29% higher risk) Prostate cancer (28% higher risk)
Stomach (22% higher risk) Colon cancer (21% higher risk)
NIOSH Study (Daniels et al., 2014)
Mesothelioma (100% higher morbidity) Rectum (45% higher morbidity)
Buccal/pharynx (40% higher morbidity) Esophagus (39% higher morbidity)
Large intestine (31% higher morbidity) Kidney (29% higher morbidity)
Lung (10% higher morbidity)
Nordic Study (Pukkala et al., 2014)
Prostate cancer (13% higher risk) The highest being 30 – 49 years old: (159% higher risk) Mesothelioma over 70 years of age (159% higher risk)
Non‐melanoma skin cancer (33% higher risk) Lung adenocarcinoma (29% higher risk)
Malignant melanoma (25% higher risk)

There is little research in the area of firefighter cancer risk perception. This may be due to the problem only recently being discovered. In order to address the issue of firefighter cancer and begin to strategically combat the issue one must first understand: what affects firefighter’s perception of increased cancer diagnosis and morbidity risks? The findings of these studies, the uniqueness of the fire service from many other industries, and the amount of risk involved in firefighting activities is the driving force behind this research study. The results of this study can be used by fire service leaders to create and adapt education programs concerning cancer awareness and prevention activities and better understand how this information is received and used. The following sections will review the existing literature and the methods used to conduct the study.

Literature Review


A risk is generally considered the part of a behavior or activity that could cause negative or undesired outcomes in the future, or the potential negative side of an activity or technology (Chauncey, 1969; Hermansson, 2012). Risk, risk assessment, and risk perception is also considered by some authors a subjective topic due to the difficulty of defining risks themselves, determining the likelihood or probability they will cause a negative effect, and the way the risk is perceived and categorized (Slovic, 1992). Sjoberg (1999, p. 129) stated that, “The very word risk is ambiguous. It carries both connotations of probability and consequence.” The risk of an activity is only one portion that individuals consider about behaviors or activities; the other variable is potential benefit. Almost all activities have potential benefits as well as risks involved (Chauncey, 1969). Chauncey (1969) also found that people are much more likely to accept increased risk when the risk is voluntarily accepted rather than imposed upon them. Ultimately, an individual must determine how safe is safe enough when considering almost every activity one is involved in which can have many variables involved (Fischhoff, Slovic, Lichtenstein, Read, & Combs, 1978). This paper will discuss risk and risk perception within the framework of the theory of reasoned action.

Theoretical Framework

One of the purposes in studying occupational risk perception in particular is behavior modification to create safer work environments. The Theory of Reasoned Action (TRA) was developed by Fishbein and Ajzen (1975). The TRA model claims that an individual’s actual behaviors are controlled by behavioral intention. The framework continues by stating that two aspects affect behavioral intention: a person’s attitude toward the behavior and their subjective norm. This is how the individual believes the important people in their life feel about whether or not the behavior in question should be undertaken (Fishbein & Ajzen, 1975). Each of the aforementioned aspects are also affected by two variables. The attitude toward the behavior is affected by an individual’s beliefs about the outcome of the behavior as well as their evaluation of the consequences of the behavior. This segment of the model is applicable to risk perception. The subjective norm is affected by normative believes of the individual’s social norm and the motivation to comply with this social norm. This segment of the model relates to organizational culture but will not be examined in depth in this study. (Fishbein & Ajzen, 1975). The model is illustrated in Figure 1.

Figure 1 (Davis, Bagozzi, & Warshaw, 1989; Fishbein & Ajzen, 1975)Theory_of_reasoned_action_TRA.jpg

While many other researchers suggest that this process is more complicated (Bandura, 1977; Fogg, 2009; Prochaska & Velicer, 1997; Schwarzer, 2008) , Fishbein and Ajzen (1975) suggest all other factors adjust behavior by having an impact on either the attitude toward the behavior or the subjective norm. Sheppard, Hartwick, and Warshaw (1988) found strong support for the TRA model’s ability to predict behavior while conducting two meta-analyses each involving over 80 empirical studies. In particular, they found that while half of the analyzed studies had applied the model to activities it was not specifically designed for, it still preformed exceptionally well at predicting behavior. Also noted was that the TRA predicted goal oriented activities as well as activities that offered explicit choices which showcases the model’s predictive ability (Sheppard et al., 1988).

Risk Perception

As stated earlier the topics of risk and risk perceptions can be especially subjective (Slovic, 1992) because many variables can play into how an individual perceives and appraises a risky activity. Pidgeon (1998) points out the fact that social science research has drastically adapted the simplistic view of risk, by highlighting the importance of the social framing of the risk as well as the important aspects surrounding how individuals perceive and measure risk. Pidgeon (1998) also points out the importance of considering the social side of risk and risk perception when developing and implementing risk management plans and regulations.

Many variables can affect risk perception. For instance, men have been found to rate several hazards and hazardous activities as lower risk than women in several studies (Brody, 1984; Flynn, Slovic, & Mertz, 1994; Gutteling & Wiegman, 1993). Flynn et al. (1994) found that white males in particular rate risks much lower than any other demographic. However, Finucane, Slovic, Mertz, Flynn, and Satterfield (2000) argues that the “White male effect” cannot simply be a biological cause but that sociopolitical views also have an effect. In their study, they found that white males did rate most of the considered risks lower than other demographics but they also differed from the other demographics on the sociopolitical spectrum. These areas were sympathy towards hierarchical, individualistic, and anti-egalitarian views, they were more trusting of technology managers, they were less trusting of government, and they were less sensitive to potential stigmatization of communities from hazards (Finucane et al., 2000). Wildavsky and Dake (1990) found that individuals perceive many risks in ways that support their chosen lifestyle. In other words, if people perceive the benefits of a particular risk will support their lifestyle choices, they may be willing to accept higher levels of risk.

In addition to the differences in gender, race and culture also have an effect on risk perception. Finucane et al. (2000) noted differences in race and risk perception, finding that nonwhite females reported the highest levels of risk perception. The study also noted that there was a great deal of variance across African-American, Asian, and Hispanic males and females. Weber and Hsee (1998) note differences in American, German, Polish and Chinese cultures when considering risky financial decisions and the perception of these decisions.

Education is an extremely important variable that has been well documented in the literature to effect risk perception and risk behavior. Studies have found that individuals with a higher level of education have a higher level of risk perception (Rodríguez-Garzón, Martínez-Fiestas, Delgado-Padial, & Lucas-Ruiz, 2016; Zare Sakhvidi et al., 2014). Education is one of the few mentioned variables in risk literature that occupational risk managers can have an effect on. By understanding what effects firefighter risk perceptions concerning cancer, awareness and education initiatives can be developed and tuned properly.

Occupational Risk Perception

Several studies have found that workers understand that their jobs can be dangerous and require them to take certain levels of risk in order to complete their task (Mullen, 2004; Sanne, 2008; Zare Sakhvidi et al., 2014). Mullen (2004) found that organizational culture and safety attitudes played into individual risk perceptions. Mullen also found that workers feel increased pressure to accept higher levels of risk because workers can perceive that management prefers performance to safety. Time sensitive jobs can also greatly affect how much risk an individual is willing to accept in order to complete the job. Honkasalo (1992) found that underwater welders felt increased pressure to accept higher levels of risk due to the time sensitive nature of their jobs. Sanne (2008) found that public railway workers in Sweden justified accepting higher levels of risks in order to complete their mission due to public safety aspects of their job, deadlines, and train schedule requirements. Lastly, Zare Sakhvidi et al. (2014) found that an increase in job tenure resulted in a lower cancer risk knowledge or perception in Iranian workers. In other words, the longer the worker had been on the job the lower their cancer risk knowledge or perception, which is opposite of what one might speculate.


Firefighter Risk Perception

Firefighters face many of the variables previously mentioned that affect occupational risk perception. Many studies have shown that firefighters are aware of the increased risks that they face while carrying out the duties of their job (Anderson, Harrison, Yang, Wendorf Muhamad, & Morgan, 2017; Jahnke, Poston, Jitnarin, & Haddock, 2012; Rodríguez-Garzón et al., 2016).  Jahnke et al. (2012) found that firefighters are becoming more aware of the risks that they face, including cancer. They also note that firefighters have noticed a shift in organizational culture toward firefighter safety and health. Similarly, Anderson et al. (2017) found that firefighters are aware of their increased risks of cancer diagnoses but unfortunately find the risks unavoidable and consider cancer just an inherent risk of performing their job.

Lastly, Rodríguez-Garzón et al. (2016) conducted a quantitative study on firefighter risk perception of firefighters in Ecuador. He found that rank in the fire service did not have an effect on risk perception. Typically, the higher one ranks in the fire service the more life and death decision that individual makes for his subordinates. One would speculate that their risk perception would increase with rank. The lack of firefighter’s risk perception studies, cancer risk perception studies in particular, is the driving force for the current project.

There are many different demographic variables that cannot be addressed in order to increase risk perception in the workplace i.e. race, gender, and culture. However, knowing this information can assist in developing and managing occupational risk management programs. Education however does have an effect on risk perception which is something that risk management can affect. There is a cancer epidemic in the fire service that must be addressed (Daniels et al., 2014; LeMasters et al., 2006; Pukkala et al., 2014); the problem is there is very little research about this newly discovered issue. Before education programs can be designed and implemented there must be an understanding of how firefighters perceive their susceptibility to cancer and what affects this perception.

Research Hypotheses and Questions

RQ 1. What affects firefighter’s perception of increased risk of cancer diagnosis and morbidity?

RH 1. Higher levels of education will result in increased levels of cancer risk perception.

RH 2. Number of years working in the fire service will have an effect on cancer risk perception.

RH 3. Rank in the fire service will not have an effect on cancer risk perception.

RH 4. Firefighters will perceive cancer as an inherent risk of their job.

RH 5. Firefighter perception of organizational culture will have an effect on cancer risk perception.

RH 6. Firefighter perception of supervisor concern for cancer risk will have an effect on cancer risk perception.

RH 7. Firefighter cancer risk perception will have an effect on taking protective actions.


The sample for this study will be firefighters that have attended certification courses at the Alabama Fire College (AFC). This study will be conducted in conjunction with the AFC. Not only do they have contact information for over 15,000 firefighters (most of which are Alabama firefighters) they have a vested interest in this research project. Understanding how firefighters perceive their risk of being diagnosed with cancer can help the AFC develop and implement education and prevention programs more effectively.

There are three types of fire departments in the United States: career, volunteer, and combination (which can be majority paid or majority volunteer). Table 2 presents Alabama fire department types as they compare to the U.S. fire service department types. One can easily see that a large study considering Alabama firefighters could be somewhat generalized to the U. S. fire service.

Table 2)  Type of Fire Departments (U. S. Fire Administration, 2014)
Department Type Volunteer Mostly volunteer Mostly career Career
Alabama 79.9% 9.0% 3.5% 7.5%
National average 70.8% 16.0% 4.5% 8.7%

In order to conduct research on how firefighters perceive their risk of occupational cancer an online survey was created following the Dillman (2011) method. The survey will be tested on 10 firefighters with similar attributes as the sample outside of the state of Alabama to ensure content validity and to refine any questions that need clarification (Creswell, 2013). The survey will then be sent to the Oklahoma State University (OSU) Institutional Review Board (IRB) for approval before being sent out by the AFC. The survey consists of two separate parts, the first is questions about cancer risk perceptions and the second is demographic information.

The survey for this study will be adapted from a previous study that measured firefighter risk perception (Rodríguez-Garzón et al., 2016). The risk perception questions will ask things such as, what do you feel the likelihood you will be diagnosed with cancer? How concerned are you about being diagnosed with cancer? Do you feel firefighting activities could increase their risk of getting cancer? The demographic questions were typical age, sex, income but also inquired about number of years in the fire service, current rank, as well as what type of fire department they were involved in. A copy of the survey is available in Appendix A. Many demographic variables affected risk perception in previous research, which will also be considered in this study. Other variables considered were not identified in past research. The independent and dependant variables are listed below.

Independent variables:

Age      Sex

Rank      Education level

Marital Status     Years in the service

Previous cancer experience   Number of fires responded to

Number of calls responded to   Type of department

Dependant variables:

Perception of their ability to control cancer risk

Perception of their ability to avoid cancer risk

Perception of their own knowledge about cancer risk

Perception of supervisor knowledge about cancer risk

Perception of long-term exposure risk

Perception of their overall likelihood of cancer diagnoses

The survey will be created in an online survey program called Survey Monkey. The anonymous feature of survey monkey will be used to ensure participant anonymity. The AFC then sent out an email, which will be used as recruitment letter and include a link to the survey. The recruitment letter will clearly state that the individual has no obligation to complete the survey and that not completing the survey will in no way affect their relationship with the AFC or OSU. A second reminder email will be sent out approximately one week later and a final reminder will be sent out one week after the second reminder.

Analysis types will depend upon the number of responses received. First, a descriptive analysis listing the means, standard deviations, and range of scores for all variables will be created. Next correlations will be run to discover correlations between independent and dependant variables. Lastly, if enough responses are received T-tests, ANOVA, and regressions could be run all using SPSS software (Creswell, 2013).


While this study may offer valuable information to the fire service there are some limitations. As with any anonymous survey that is trying to target a group, you can never know who is actually completing the survey. Another problem that could present in this study is the fact that it is an email survey. The email address the AFC has on file may no longer be the individual’s primary email or the individual may only check their email when they are expecting something such as test results. Lastly, is a problem with answering questions honestly. Because of fire service culture firefighters may feel pressure to answer the question in a way that molds to their organizational culture.


Anderson, D. A., Harrison, T. R., Yang, F., Wendorf Muhamad, J., & Morgan, S. E. (2017). Firefighter perceptions of cancer risk: Results of a qualitative study. American journal of industrial medicine, 60(7), 644-650.

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Chauncey, S. (1969). Social Benefit versus Technological Risk. Science, 165(3899), 1232-1238.

Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods approaches: Sage publications.

Daniels, R. D., Kubale, T. L., Yiin, J. H., Dahm, M. M., Hales, T. R., Baris, D., . . . Pinkerton, L. E. (2014). Mortality and cancer incidence in a pooled cohort of US firefighters from San Francisco, Chicago and Philadelphia (1950–2009). Occup Environ Med, 71(6), 388-397.

Davis, F. D., Bagozzi, R. P., & Warshaw, P. R. (1989). User Acceptance of Computer Technology: A Comparison of Two Theoretical Models. Management Science, 35(8), 982-1003. doi:10.1287/mnsc.35.8.982

De Lisi, S. M. (2005). Organizational culture in the fire service. Fire Engineering, 158(8), 119.

Dillman, D. A. (2011). Mail and Internet surveys: The tailored design method–2007 Update with new Internet, visual, and mixed-mode guide: John Wiley & Sons.

Finucane, M. L., Slovic, P., Mertz, C. K., Flynn, J., & Satterfield, T. A. (2000). Gender, race, and perceived risk: the ‘white male’ effect. Health, Risk & Society, 2(2), 159-172. doi:10.1080/13698570050077390

Fischhoff, B., Slovic, P., Lichtenstein, S., Read, S., & Combs, B. (1978). How safe is safe enough? A psychometric study of attitudes towards technological risks and benefits. Policy sciences, 9(2), 127-152.

Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior: an introduction to theory and research.

Flynn, J., Slovic, P., & Mertz, C. K. (1994). Gender, race, and perception of environmental health risks. Risk analysis, 14(6), 1101-1108.

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Jahnke, S. A., Poston, W. S., Jitnarin, N., & Haddock, C. K. (2012). Health concerns of the US fire service: perspectives from the firehouse. American Journal of Health Promotion, 27(2), 111-118.

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Pukkala, E., Martinsen, J. I., Weiderpass, E., Kjaerheim, K., Lynge, E., Tryggvadottir, L., . . . Demers, P. A. (2014). Cancer incidence among firefighters: 45 years of follow-up in five Nordic countries. Occup Environ Med, 71(6), 398-404.

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Firefighter Cancer Risk Perception Survey

1. Do you think you have enough knowledge about occupational cancer risks you may face?

Nothing known       Know precisely

1  2  3  4  5

(This question explores firefighter perception of their own cancer risk knowledge)

2. Do you think your supervisors are properly informed about occupational cancer risks you may face?

Nothing known       Know precisely

1  2  3  4  5

(Explores firefighter’s perception of managements knowledge of cancer risks)

3. How concerned are you about being diagnosed with cancer?

Not concerned       Extremely concerned

1  2  3  4  5

(Explores the fear factor, firefighter’s concern about cancer diagnosis)

4. What do you think is the likelihood you would be diagnosed with cancer?

Not likely       Extremely likely

1  2  3  4  5

(Explores firefighter’s perception of the likelihood of facing cancer)

5. Do you think that situations you face while involved in firefighting activities exposes you to agents that cause cancer?

No exposure       Extreme exposure

1  2  3  4  5

(Explores the degree of exposure or seriousness of the consequences


6. Can you take actions to prevent cancer causing carcinogen exposure?

I can do nothing       I can do many things

1  2  3  4  5

(Explores firefighter’s perception of their ability to avoid the exposure)

7. How likely would you be to regularly take preventative actions?

Not likely       Extremely likely

1  2  3  4  5

(Explores firefighter’s perceived control over the exposure)

8. How likely do you think you and your crew are to be exposed to cancer causing agents that could rapidly affect your health?

Not likely       Extremely likely

1  2  3  4  5

(Explores the firefighter’s perception of mass/ catastrophic cancer exposure risks)

9. Do you think that you are exposed to cancer causing agents that could have a delayed effect on your health?

Strongly disagree      Strongly agree

1  2  3  4  5

(Explores firefighter’s perception of long-term cancer exposure risks)

10. If you were diagnosed with cancer what do you think the likelihood is of it being caused by participating in firefighting activities 0 (not caused by firefighting activities) 100 (absolutely caused by firefighting activity exposure? ___________


(Explores the firefighter’s overall cancer risk perception)

11. Have you or any of your fellow firefighters ever been diagnosed with cancer?

  • Myself
  • Coworker
  • None

12. What type of fire department are you affiliated with?

  • Career
  • Volunteer

13. How many years have you been in the fire service?

  • 0-4
  • 5-9
  • 10-14
  • 15-19
  • 20 or more

14. What is your current rank?

  • Firefighter
  • Apparatus Operator
  • Lieutenant
  • Captain
  • Battalion Chief
  • Chief Officer

16. How many calls for service does your department respond to (approximately)?

  • 0-499
  • 500-1,499
  • 1,500-2,499
  • 2,500-4,999
  • 5000 or more

17. How many fire related calls (structure, dumpster, vehicle, wildland) does your department respond to annually?

  • 0-24
  • 25-49
  • 50-74
  • 75-99
  • 100 or more

18. How old are you

  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55 and up

19. What is your sex?

  • Male
  • Female

20. Marital status

  • Married
  • Divorced
  • Single
  • Widowed

21. Education level

  • GED
  • High school diploma
  • Some college
  • Associates degree
  • Bachelors degree
  • Graduate school

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