Causal inference in occupational epidemiology: accounting for the healthy worker effect by using structural nested models

Am J Epidemiol. 2013 Dec 15;178(12):1681-6. doi: 10.1093/aje/kwt215. Epub 2013 Sep 27.


In a recent issue of the Journal, Kirkeleit et al. (Am J Epidemiol. 2013;177(11):1218-1224) provided empirical evidence for the potential of the healthy worker effect in a large cohort of Norwegian workers across a range of occupations. In this commentary, we provide some historical context, define the healthy worker effect by using causal diagrams, and use simulated data to illustrate how structural nested models can be used to estimate exposure effects while accounting for the healthy worker survivor effect in 4 simple steps. We provide technical details and annotated SAS software (SAS Institute, Inc., Cary, North Carolina) code corresponding to the example analysis in the Web Appendices, available at

Keywords: causal inference; healthy worker effect; marginal structural models; occupational epidemiology; structural nested models.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Comment

MeSH terms

  • Female
  • Humans
  • Male
  • Neoplasms / epidemiology*