To what extent can attributable fractions in occupational epidemiology be estimated in the absence of key data?

Abstract In a recent paper, Ghoroubi et al. (Am J Epidemiol 2025 Jan 8;194(1):302-310) used the indirect attributable fraction (AF) method to provide estimates of fractions of all-cause mortality attributable to work-related factors. This commentary discusses the limitations and potential of this paper and provides insights and guidance to make optimal use of indirect AF estimation in occupational epidemiology. The crucial steps are the choice of the datasets and input data related to the prevalence of exposure and relative risk (RR), requiring comparability of time period, population characteristics, and the definition and measurement of exposure. Published systematic literature reviews with meta-analyses are essential or, if not available, conducting meta-analyses to provide estimates of RR. Finally, it is important to verify the assumptions for the chosen AF formula including evidence of causality, consideration of confounding and (in)dependence between exposures when several exposures are studied at the same time. We conclude by suggesting that the paper by Ghoroubi et al. may have provided a proof of concept for 1 work-related factor only, but considerable additional research will be required to represent work-related factors overall.