Data Sheet 1_Non-cancer mortality among firefighters: a meta-analytic review of heart disease, stroke, respiratory disease, liver disease, accidents, and suicide.docx

IntroductionFirefighting is a hazardous occupation linked to elevated cancer risk. However, occupational exposures unique to this profession may also contribute to non-cancer morbidity and mortality. To better understand firefighters’ health risks, it is essential to examine causes of death beyond cancer.
MethodsFollowing PRISMA guidelines, we conducted a systematic review and meta-analysis of population-based studies published between 1978 and 2025. Studies reporting standardized mortality ratios (SMRs) for non-cancer causes of death were identified through database searches. We estimated pooled SMRs and 95% confidence intervals using random-effects models, tested for publication bias and study quality, and conducted moderator analyses.
ResultsTwenty-five studies were included for final meta-analysis. Firefighters exhibited significantly lower mortality rate for heart disease (SMR = 0.64; 95%CI: 0.51–0.80), cerebrovascular disease (SMR = 0.67; 95%CI: 0.50–0.90), diabetes mellitus (SMR = 0.48; 95%CI: 0.32–0.70), intentional self-harm/suicide (SMR = 0.52; 95%CI: 0.39–0.70), chronic lower respiratory disease (SMR = 0.71; 95%CI: 0.55–0.91), and accidents/injuries (SMR = 0.77; 95%CI: 0.62–0.98) compared to the general population. In contrast, evidence for respiratory infections (k = 3) and liver disease (k = 6) was sparse and mortality estimates were comparable to those in the general population. Meta-regression analyses revealed no significant difference across studied moderators including study location, occupational data sources, incident types attended, gender, race, employment status, smoking status, or study quality score on the observed mortality patterns.
ConclusionFirefighters experience lower mortality from multiple non-cancer causes, potentially due to occupational fitness requirements and the healthy worker effect. However, parity in mortality from liver disease and pneumonia/influenza warrant further investigation into behavioral factors and occupational exposures. Our results refine the healthy worker effect by identifying cause-specific gaps and priorities for targeted prevention and surveillance.