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The Sheet Metal Occupational Health Institute Trust (SMOHIT) established a screening program in 1985 to examine the health hazards of the sheet metal industry in the U.S. and Canada.17,345 individuals with over 20 years in the trade and who participated in the program were followed for causes of death between 1986 and 2010. Both SMRs and Cox proportional hazards models investigated predictors of death due to lung cancer, mesothelioma, and chronic obstructive pulmonary disease (COPD).Significant excess mortality was seen for mesothelioma and asbestosis. Controlling for smoking, a strong trend for increasing lung cancer risk with increasing chest x-ray profusion >0/0 was observed. With an profusion score <1/0, FEV1 /FVC <80% was associated with lung cancer risk. COPD risk increased with increasing profusion score.This study demonstrates asbestos-related diseases among workers with largely indirect exposures and an increased lung cancer risk with low ILO scores. Am. J. Ind. Med. 58:378–391, 2015. © 2015 Wiley Periodicals, Inc.