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1969 s~mP~ To The i~o? Public Eealth Service Review July i~ 1969

THE h~ALTH CONSEQUenCES OF BMOEI[NG 1969 SI~ i. Ac ~uowlCdgmea bs Sum~1~ry o~' th~-~eport Smoking and Cardiovascular Diseases Smoki~l~ ~d Chronic ODstruct]v~ Bro~chopL~l~omary Dise~s~ 5- Sm~klng and Cancer Effo~t~ o~ S~king on prega~ncy 7- Smoking and Noncancerous Oral Disease

b $UP~RY OF TItE REPORT This report is a review o£ the pertinent ~edlcal literature on the health consequences of smoking which has appeared since the publlcation of rbe 1968 Supplement to the i967 ~ubllc Health Service Review. The 1964 Report of the Advisory Comlttee on Smoking and Health, the 1967 Pchllc Health Service Review and rbe i968 Supplement bare presen=ed the broad base of converging epldemielogical, physlologlcal, pathological and clinlcal evidence on which knowledge of¸ the health hazards of smokln8 is ba6ed, included in this evidence are da~a whlch sho~ che magnitude of che excess ~ortallty ~d morbldlty ~ong smokerso The followlng co~clusloas ~ega~dlng the heal~ Consequences of smokln8 were s~arlzed in ~he 1968 Supplement. Genecal Mortality Informatlon Pr~vlous findings reported in 1967 Indicate that cigarette smoking is associated with an increase in overall mortality and morbidity and leads to a substantial excess o£ dsaths i~ those peopl~ who smok~, In ~dditle~ ~vide~ herein prese~d sh~s ~ha~ llfe ~xpe~amcy ~ong you~8 ~en is reduced by an average of 8 years in '~eavy" cigare~te smokers~ those who ~m~ke over ~wo pa~k~ a day~ ~nd an ~ver~ge of 4 yea~ in '111ght~ ~igarette smokers, ~hose who ~moke less than one-h~if pack per day° Emokin8 and Cardlovascular Disease~ Curren~ physiological e~idence, i~ combinatlo~ wich addltio~al epide~iological evidence, conflrme p~vious findings ~nd ~ugge~ts addlt±on~l biomechanlsms whereby clgaret~e ~moking c~i e~atribute ~o coron~t~ he~t dive.See Cigarette 8moklng adve~saly affect~ rbe inte~actlon be~w~ea~ the demand of the hea~ for oxygen a~ other nutrlents and their supply. Some of the harmful cardlo~ v~scula~ effect~ a~pea~ to be reversible af~e~ ces~tlon of clgare~e ~mo~. ~=~

Because of ~be increasing convergence of epidem/ological and physiological findings relating cigarette smoking to coronary heart disease~ it is concluded ~hat cigarette smoking can con- tribute to the development of cardiovascular disease and partic- ularly to death from coronary he~r~ disease. Smoking and Chronic Obstructive Brenchopulmonary Diseases Additional physiological and epidemlologlcal evidence confirms the previous findings that cigarette smoking is the most important cause of chronic non-neoplastic hronchopulmonary disease in the United grates. Cigarette smoking can adversely affec= pulmonary function and disturb cardiop~imonary physiology. It is suggested =ha~ this nan lead =o cardiopulmonary disease, notably pulmonary hyper- tension and cot pulmonale in those individuals who have severe chronic obstructive bronchi=is. Smoking and Cancer Additional evidence substantiates the previous findings that cigarette smoking is the main cause of lung cancer in men. Ciga- rette smoking is causally related to l'~g cancer in women but accounts for a smaller proportion of cases than in wen. Smoking is a significant factor in the causation of c~cer of the larynx and in the development of cancer of the oral cavity. Further epidemiological data strengthen the association of cigarette smoking with cancer of the bladder and cancer of the pancreas, The rues6 r=cent Public Realth Service review of the effects of smoking on pregnancy was presented in the 1967 Report. The conclusions of ~hat review were as follows: Clearly, more research is needed to elucidate the siEaificance of the relationship of smoking in pregnancy and low birth weight. Addi=ional long-range morbidlty studies are needed, as well as s~udies on the effect of smoking on uterine activity and placental blood flow. Smoking does have an effect on the outcom~ of pregnancy. Eow- ever, it is no= k~0wn whether this effect is deleterious or no=.

C Until such evidence is presented so as to clearly define the role of smoking in pregnancy, it is more prudent at this time to advise pregnant women to stop or decrease thelr edgarette- smoking practices. No substantial negative evidence has appeared which refutes these Judgments. On the contrary, studies made available since ~he publication of the 1968 Supplement and reviewed by panels of experts in the relevant medical areas confirm previous findings and add new evidence that smoking is a health hazard. Highlights of the 1969 Supplement are as follows: I. ~ and Cardiovascular Diseases: Further data from prospective studies eonflrm the Judgment that ciga- rette smoking is a significant risk factor that contributes to the develop- ~an~ of coronary heart dlsease~ apparently by promoting myocardial infarct and cardiac arrhythm±as. Analyses by several investi~tors of othe~ 8~soclated factors (high ser~ cholesterol, high blood pressure and body weight) show clearly that the effect of cigarette smoking persists and is appreciables even when these other factors are carefully evaluated. Autopsy studies suggest that cigarette smoking is associated with a significant increase in atherosclerosis of the aorta and the coronary ar~erles. Experimental studies dn animals have provided new information on the pathological effects of cigarette s~king on the arteries. This further supports the view that cigarette smoking promotes aKherosclerosIs. GO

il, s~kinjl and Chronic Obstructive Broncho ulmona Diseases; Recent studies have demonstrated that cigarette smokers m~y have significant disease of the small airways in the absence of bronchopulmonary symptoms. This disease is demonstrated by the finding of abnormalities in the ventilatlon/perfuslon relationships in the lungs of cigarette smokers. Animal experiments have demonstrated the pathological effects caused in the lung by exposure to clgare=te smoke or to specified concen- trations of products found in cigarette s~ke. Conditlons similar to pulmonary e=.physema in man have been produced in some of these experiments. Other studies have inves=igated the pa=ho~ogical effects of smoking on pulmonary clearance mechanisms and demonstrated that pulmonary clearance may be signlfican=ly impaired by =he effec=s of cigarette smoking. Kpidemfological a~d laboratory evidence supports the view ~ha~ cigarette smoking can contribute to the development of pul~onary emphysem~ in =~n. l£I. S~kln~ and Cancer: A major pathological study of histological changes i= the larynx has de~nstrated a dose-relationship between smoking ~id pre~llgnant changes in the larynx. New animal models for ~he experimental study of respiratory cancer, which may be helpful in e~ucidating the mschanlsms of respiratory ~r~cc carelnogenesis, have been developed and refined. More studies have been done =o £den=ify those subs=antes in tobacco smoke which ~O

cake part in carcinogenesis. ~lese studi~s may help t.o define the exact biomechanisms involved in the cause and effect relationship between ciga- rette smoking a~d lung cancer. IV. Effects of S~k~/~ on P~: New data are presented which ~onfirm the finding that maternal smoking during pregnancy is associated wiKh low birth weight in infants ~nd also indinate that mnterz%al smoking is associated with an increased incldeRce of prematuri=y defined by welghK alone, l~ addition, it appears that m~ter~ai slnohing during pregnancy may b~ associated with ~u~ increased incidence of spontaneous ahor=ion, sKillblrth and neonatal death and that this relationship may be most marked in =he presence of other risk factors. V. $mokin~ and Noncancerous Oral Dlsease~ The chapter on noncancerous oral disease is the first Publla Health Service review of this sub~eet. The data available lead ~o the conclusion that ulceromembranous gingivitis, alveolar bone loss a~d sto~a~dtds ~ico~ina are ~re eo~mnly found among s~kers ~han a~ng no~smokers° ~%e i~fluenee of smoklng on periodon=al disease and gingivitis probably operates in con- j~uc=ion wlth poor oral hygiene. In addi=ion, there is evidence =hat smoking may be associated wlth ede~tulism and delayed soeke~ healing. Tobecco smoke contains a large number and ~ wide variety of compounds which may ~esul~ in co~i~x and multiple pa~ho-physlologlcai effects o~ the varioms tissues and orga~ sys=ems. While further research is needed ~o -J

Investlgate the e~ac~ biomeehanlsms involved in the paKhological ~ffec~s of s~klng, the ev£~en~e clearly shows that clgaret~e smoking constituteo a major health hazard in ~he Oni~ed States. 6

ACK NOWLEDGMEh~S The National Clearinghouse for Smoking and Health, Daniel Horn, Ph.D.~ Director~ was responslble for the preparation of thls report; Albert C. Kolbye, Jr.~ M.D.. M*P.H.~ LL.B., was consulting editor. Staff director for ~hls report was Daniel P. Ashes, M.D. The professional staff has had the assistance and advice of a number of experts in ~he scientific and technical fields, both in and outside of ~he Government. ~elr con~rlbutlons are gratefully acknowledged. Special thanks are due ~he following: ANDERSON, WILLIAM }I., M.D.--Associate professor of medicine, University of LouSsville, School of Medicine, Lo,~i~ville, Ky° AL~F~BACH, 0SC~, M.D.--Senior medleal investigator, Veterans Administration Hcspi~al~ East Orange~ N.J. AVIADO, DOMINGO M., M.Dq--Professor of pharmacology, Departmen~ of Pharma- cology, School of Medicine, University of Pennsylvanla~ Philadelphla, Pa. AYI~E~, SEEPHEN M., M.D.--Director, Cardiopulmcnary Laboratory, Saint Vineen~ts Hospital and b~dical Center of New York~ ~New York~ N.Y. BATES, DAVID V., M.D.--Cha£rman, Department of Physiology, MeGill Univer- sity, Montreal, Quebec, Canada. BELLET, S~EL, M°D.--Direetor, Division of Cardiology, Philadelphia General Hospital, Philadelphia, ~a. BINC~ RI~AP~ J.. M.D.--Professor and chairman, Department of M~dicine~ Wayne S~a~e University, Detroit, M~ch. BLOMQUIST, EDWARD T., M.D.--Chief, Chro~ic Respiratory Disease Control Frog~am, Health Services and ~ntal }{eal~n Adm~nistratlon, U.S.P.H.S~, Arling ~on. Va.

BOOK, FRED O., Ph. D.--Director, Orchard Park Laboratories, Noswell Park Memorial Ius~itute, Orchard Park, N.¥. BOREN, BOLLIS, M.D.--Chlef of pulmonary disease, Professor of medicine, Marquette~ School of Medicine, Wood VA Center, Milwaukee, Wise. BOUTWELL, ROSWELL K., M.D.--Professor of oncology, McArdle Laboratory for Cancer Research, University of WisconslnI Madisonj Wise. COOPER, THEODORE, M.D.--Director, National Heart instltu=e, National institutes of Health, Bethesda, Md. CORNFIELD, JgROME--Biostatlstfcs Project, Bethesda, Mdo DE LA PUENTE, JOSEPH--Chlef, Program Studies Section, Kidney Disease Con- trol Program, Health Services and Mental Health Administration, U.S.P.M.S., Arlington, Va. EASTMA~I, NICNOLSON J., M.D.--Professor emeritus of obstetrlcs, Johns Hopkins Hospital, Baltimore, Md. ELIOT, ROBERT S., M.D.--Assoclate professor of medicine. Divlsi0~ of Cardlolosy, College of Medleine~ University of Elorlda~, Galnesvllle, Fla. E~DICODT, KENNETH M., M.D.--Director, Natioual Cancer Institute, National Tnstltutes of Health, Bethesda, Md. EPSTEIN, FREDERICK H.. M.D.--Professor of epldemiology, Department of Epldemlology, Unlversi~y of Michigan, School of Public Health, Ann Arbor, Mich. FALK. HANS L,i Ph. D.--Assoclate director for laboratory researehp National Institute of Environmental Health Sciences, Research Trian8le ParkI S.C. FERRIS, BENJAMIN G., JR., M.D°--Prefessor. Department of Physlolosy~ Harvard School of Public Health, Harvard University, Boston, Mess. FOX, SAMUEL M.i lli, M.D.--Chiefi Heart Disease and Stroke Control Pro- gram. Health Services and Mental Health Admlnis~raKion, U.S.P.H.S., Arlington, Va. G~