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The Health Consequences of Smoking for Women A Report of the Surgeon General - Part 1 of 4
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WOMEN AND THE CHANGING CIGARETTE
As this report documents, the proportion of men and women
smokers using brands with lowered "tar" and nicotine
continues to grow. Adolescents of both sexes have followed
this trend~, to the point where nonfilter cigarettes are
relatively rare among young adults.
Although the preponderance of scientific evidence
continues to suggest that cigarettes with lower "tar" and
nicotine are less hazardous, four seriouss warnings are In
order.
First, the reported "tareand nicotine deliveries of
cioarettes are standardized machine measurements. They do
not necessarily represent the sm oker's actual intake of these
substances. Evidence is now mounting that individuals who
switch to cigarettes with lowered "tar" and nicotine inhale
more deeply, smoke a greater proportion of their cigarettes,
and inn some cases smoke more cigarettes. '
Second, "tar" and nicotine are not the only dangerous
chemical components of cigarette smoke. Many conventional
filter cigarettes, in fact, may deliver more carbon monoxide
than nonfilter cigarettes. Third, it has not been established that lower "tar"and
nicotine cigarettes have less harmful effects on the unborn
fetus and baby; on women and men at high risk for developing
coronary heart disease, suchh as those with elevated cholesterol
or high blood pressure; or on workers with adverse
occupational exposures. It has not beenn established that
switching to a lower "tar" and nicotine cigarette has any
salutory effect on individuals who already have sm oking-
relatedillnesses, such as coronary heart disease, chronic
bronchitis, and emphysema.
Fourth, even the lowest yield cigarettes present health
hazards for both. women and men that are very much higher
than smoking no cigarettes at all. The single most effective way for both women and men
smokers to reduce the hazards associated with cigarettes is
to quit smoking.
As this report demonstrates,li6tle is known about thee
effects of these product changes on the initiation,
maintenance and, cessation of sT oking, particularly among
women. It has not been determined whether the availability
of cigarettes with lowered "tar" and nicotine has made it
easier for young womenn to experiment with and becomee
addicted tocigarette.s. It is not known whether smokers of
vii
Concepts of Adolescent Behavior
...... .319
Prevalence and Patterns of
Adolescent Cigarette Uke....... 320
Prevalence ..................... 321
Age of initiation in
,
smoking ........................ 323
Number of cigarettes smoked ..... 326
Type of cJgarette smoked ........ 326
Smoking Cessation. ...............
Smoking prevalence and ethnicity 328
................................328
Alcohol and marijuana use ....... 329
Demographic and Psychosocial Correlates
of Smoking In Adolescence ............. 329
Socioeconomic influences ........ 329
Family patterns ................. 330
Smoking among parents and
- siblings ........ 330
Peer group influenc.e............ 332
Scholastic achievement and
aspirations .................... 334
Dynamic/Personali'tyfactors..... 334
Predictions of future smoking
behavior ....................... 336
Prevention of Smoking and Considera- tions for Future Research............. .338Prevention of the
Initiation of
smoking ........................ 338
Research goals.................. 339
iAaintenanceof Smoking................. 340
Smoking Behavior ................ 340
- Patterns of cigarette -
. smoking................... .340
Smoking prevalence and
ethnicity ................. 345
Pharmacological Effects of
Smoking ........................ 345
Nicotine................... .347
Peripheral effects....347
Central effeats....... 347
A possible role for nico-
tine in smoking mainte-
nance..................... 347
Differences in nicotine
metabolism ................ 350
xxiii
1965 toan estimated 3,900 in 1979. From 1965 to 1979,
the proportion of adult male cigarette smokers declined from
51 to 37' percent. Not only have millions of men quit
smoking,., but the rate of initiatiom of smoking among
adolescent males has now slowed. .
From 1965 to1976, the proportion of adult women
cigarette smokers rem ained virtually unchanged at 32 to 33
percent. Since 1976, however, the proportion of adult women
cigarette smokers appears to have declined to 28 percent.
Although adult women are now beginning to quit sm oking at
rates comparable to adult men, the rate of initiation of
smokingamong younger womenn has not declined.
This report documentss numerous differences by sex in
the perceived role of cigarette smoking, in attitudes to ward
health and lifestyle, and in methods of coping with stress,
anger, and boredom.. Yet thee significance of these
differences, and their relation todiEferences in smoking
patterns, remains poorly understood. .
Although it is freqpently observed that women in
organized smoking cessat'iomn programs have more severe
withdrawal symptoms and lower rates of successful quitting
than men, these observations have not been systematically
confirmed for the general population. In the past, women
may have attempted' to quit or succeededin quitting, smoking
less frequently than men. The recent decline in the propor-
tion off women smokers, however, suggests that women's
attempted and successful quitting rates have now increased.
Althoughh weight gain is a frequently cited consequence
of quitting smoking, the association of weight gain with
cessation of smoking has not been the subject of sufficient
scrutiny. Controlled studies with careful measurement on
representative populations of women do not exist. The impact
of the fear of weightt gain after quitting has not been ade-
quatelyexamined. If weight gainn does result from cessation
of smoking, its exact mechanism must bedetermihed.
Even more problematic are marked differences by sex
in the distribution of smoking prevalence by occupation. Men
with advanced education and professional occupations have
taken the lead io-quitt'ing snoking, but women in
administrative and managerial positions have relatively high
smoking prevalence rates. Although 20 percent or fe wer male
physicians smoke, the proportions of cigarette smokers among
women health professionals, especially nurses and
psychologists, remain disturbinglyhioh.
Recent changes in smoking prevalence among black
V
Director, Pulm onary Division, University of
California, San Diego, California.
Mariauita Mullan, National Instituteof Occupational
Safety and Health, Rockville, Maryland.
Janyce E. Notopoulos, Program Analyst, Office of
Planning and Evaluation, National Institute of
Child Health and: Human Development, National
Institutes of, Health, Bethesda, Maryland.
Albert Oberman,M.D., Director, Division of
Preventive Medicine, School of Medicine, University
of Alabama, Rirmingham, Alabama.
Ralph, S. Paffenberger, Jr., M.D., Professor of
Epidemiology, Department of Health Services,
California State Health. Department, Berkeley
California. . Richard Peto, M.D., P,adcliff Clinic, Oxford
University, Oxford, England.
Malcolm C. Pike, Ph.D., Professor, Community and
Family M edicine, School of P^edicine, University
of Southern Californla at Los Angeles, Los Angeles,
California. - Ovide P.. Pomerleau, Ph.D., Professor ofPsychologvand Psychiatry, University of
Connecticut School of-
Medicine, Farmington, Connecticut. Phill H. Price, M.D., Chief, M etabolic Products
Franch, Division of Ruminant Species, Pureau of
Veterinary Medicine, Food and tlrug Adminl!stration,
Rockvllle, Maryland. Mrs. Dorothy Pechman Rice, Director, National Center
for Health Statistics, Office of the Assistant
Secretary for Health. Hyattsvile, Maryland. Anthony Robbins, M.D., Director, National Institute
of Occupational Safety and Health, Center for nisease
Control, Rockville, Maryland.
Harold P. Roth, M.D., Associate Director for
Digestive Diseases R Nutrition, National Institute of
Arthritis, M etabolism, and Digestive Diseases,
National Institutes of Health, Rethesda, Maryland.
Philip. Sapir, Special Assistant to the Director for
Rehavioral and Social~ Sciences and Chief, Human
Learning and Behavioral Branch, Center for Research
for Mothers and Children, National Institute of Child
Health and Human Development, National. Institutes of
Health,. Bethesda, Maryland.
M arvin A. Schniederman, Ph.D., Associate Director for
xvi
the newborn baby. These damaging effects have been
repeatedly shown to operate independently of all other factors
whichh influence the outcome of pregnancy. The effects are
increased by heavier smoking and are reduced if a womann
stops smoking during pregnancy.
Numerous toxic substances in cigarette smoke, such as
nicotine and hydrogen cyanide, cross the placenta to affect
the fetus directly. The carbon monoxide from cigarette smoke
is transported into the fetal blood and deprives the growing
baby of oxygen. Fetal growth Is directly retarded. The
resulting reduction in fetal weight and size has many
unfortunate consequences. Women who smoke cigarettes during
pregnancy have more spontaneous abortions, and a greater
incidence of bleeding during pregnancy, premature and',
prolonged, rupture of amniotic membranes, abruptio placentae
and placenta previa. Women who smoke cigarettes during
pregnancy have more fetal and neonatall deaths than
nonsmoking pregnant women. A relation between maternal
smoking and Sudden Infant Death Syndrome hass now been
established.
The direct harmful effects of smoking on the fetus
have long term consequences. Children of mothers who
smoked during pregnancy lag measurably in physical growth;
there may also be effects on behavior and cognitive
developm ena. The extent of these deficiencies increases with,
the number of cigarettes smoked. Thedamagingeffectse of maternal sm oking on infants
are not restricted topregnancy. Nicotine, a knowm, poison, is
found in the breast milk of smoking mothers. Childremn whose
parents sm oke cigarettes have more respiratory Infections and
more hospitalizations in the first year of life. Women who smoke cigarettes have more than three
times the risk of dying of stroke due to subarachnoidd
hemorrhage, and as much as two times the risk of dying of
heart attack in comparison to nonsmoking women. The use of
oral contraceptives in addition to smoking, however, causes a
markedly increased risk,, including a 22-fold increase in the
risk of subarachnoid hemorrhagic stroke and a20-fodd'
increase in heart attack in heavy smokers.
WHY DO WO'4EN SrtOKE?
Cigarette consumption in this country is now declining.
Annual per capita consumption has decreasedfrom 4,258 in
iv
NON-NEOPLASTIC BRONCHJPULMUNARY DISEASES........... 160
Definitions ............................ 160
Smoking and Respiratory Mortality ...... 161
Smoking and the Epidemiology and
Pathology of Chronic Obstructive Lung
Disease ............................... 166
Smoking and Respiratory Morbidity...... .173
Smoking and Pulmonary Function......... ..182
Smoking and "Early" Functional
Abnormalities .................. 183
Smoking and Ventilatory
Function....................... ...187
INTERACTION BETWEEN SMOKING AND OCCUPATIONAL
EXPOSURES ............. ..............................203
Smoking Patterns in Women.............. .204
Patterns of Employment................. .208
The Reproductive Roie.................. .213
Specific Interactions Between
Occupational Exposure and Smoking ..... 215
Asbestos ........................215
Cotton Dust ..................... 218
PREGNANCY ArD INFANT HEALTH .........................224
Smoking, Birth Weight, and Fetal Growth
................................224
Placental Ratios ................ 226
Gestation and Fetal Growth ...... 229
Long Term Growth and Development
. ...................................230
Role of Maternal Weight Gain....237
Smoking Fetal and Infant Fbrtality and
Morbidity ............................. 243
Spontaneous Abortion ............ 243
Congenital Malformati'.ons........ 245
Perinatal Mortality ............. 250
Cause of Death .................. 252
Complications of Pregnancy and Labor...254
Preecl.amsia ..................... 256
Preterm Del~ivery, PregnancyComplicati.ons and Perinatal
Mortality by Gestation ........ 258
Long Term Morbidit'yand Mortality...... 263
Sudden Infant Death Syndrome.... 266
xxi
Richard A. Lasco, Ph.D., Pureau of Health, Educat:ion,C.enter for Disease Control, Atlanta, Georgia.
Frances Lazerow, Vice -President, Koba Associates,
Washington, D.C.
Joanne Luoto, M.D.,. N.P.H.. Medical Office, Office on
Smoking and Health, Rockville,. Maryland.
Jack P. Maples, Senior Research Associate, Koba
Associates, Washington, D.C. Marianne P. McCarthy, Ph.D., Director of Technical
Support Services, Koba Associates, Washington, D.C.
Marjorie L. Olson, Secretary (Stenography), Office on
Smoking and Health, Rockville, Maryland.
Kelley L. Phillips, M.D,, M.P.H., F.xpert Consultant,
Officeon Smoking and Health, Rockville, Mayland.
David L. Pitts, Public Health, Advisor, Operations
Pranch, Nutrition Division, Runeau of Sm ailpoxEradication, Center for nisease Control, Atlanta,
Georgia.
Donald. R. Shopland,Technicai Information Officer,
Office on Smoking and Health, Rockville, Maryland.
Linda R. Spiegelman, Administration Assistant,
Office on fmoking and Health, Rockville, Maryland.
Carol M. Sussman, Technical. Publication
WriterJEditor, Office on Smoking and Health,
Rockville, Maryland. RonaldG. Thomas, Pubiic Health Analyst, Office on
Smoking and Health, Rockville, Maryland.
Selwyn. M. Waingrow, Public Health Analyst, Office on
$moking and Health, Rockville, Maryland.
Ann E. Wessel, Public HealtK Analyst, Office on
Smoking and Health.,. Rockville, Maryland.
CaroleG. Winn, Assistant. Chief, Clinical Chemistry
Standardization Section, Clinical Chemistry Division,
MetabolicRiochemistry Rranch, Rureau of
Laboratories, Center for Disease Control, Atlanta,
Georgia.
Development, National Institutes of Health, Bethesda,
M aryland. Lester Breslow, M.D., M.P.H., Dean, School of Public
Health, University of California at Los Angeles, Los
Angeles, California..
A. Sonia Buist, M.D., Associate Professor of Medicine
& Physiology, University of Oregon Health Sciences
Center, Portland, Oregon.
David M. Burns, M.D., Assistant Clinical Professor,
Pulmonary Divisiony University of California at San
Deigo, San DieRo California.
Thomas C. Chalmers, M.D., President and Dean, Mount
Sinai Medical Center, New York, New York.
Florence L. Denmark, Ph.D., Professor of Psychology,
Ph.D. Programs in Psychology, City University of New
York, New York, New York..
Rohert M. Donaldson, Jr., M.D., Chief, Medical
Services, Westhaven Veterans Hopital, Westhaven,
Connecticut.
Joseph T. Doyle, M.D., Professor of Medicine and
Head, Division of Cardiology of the Department of
Medicine, Albany Medical College of Union University,
Albany, New York.
Elizabeth M. Earley, Ph.D., Chief, Section of
Cytogenetics, Division of Pathology, Bureau of
Biologics, Food and Prug Administration, Rockville,
M aryland.
Bernard H. Ellis, Jr., Program Director for Smoking
and Occupationall Activities, Office of Cancer
Communications, National Cancer Institute, National
Institutes of Health, Bethesda, Maryland.
Diane Fink, M.D., Associate Director, M edical
Applications of Cancer Research andCoordinator,
Smoking, Cancer, and Health Program, National
Cancer Institute, National Institutes of Health,
Bethesda, Maryland. Harold E. Fox, M.D., Associate Professor of Clinical
Obstetrics and Gynecology, Department of Obstetrics
and Gynecology, Columbia Presbyterian Medical Center,
an& Medical Director, Western and Upper Manhattan
Perinatal Network, New York, New York.
Joseph H. Gainer, D.V.M., Veterinary Medical Office,
Division of Veterinary Medical Research, Bureau of
Veterinary Medicine, Food and Drug Administration,
Rockville, Maryland.
xiv
Stanley N. Gershoff, Ph.D., Director, Nutrition
Institute and Chairman, Graduate Department of
Nut.rition, Tufts University, Medford, Massachusetts.
Sharon P4. Hall, Ph.D.,. Assistant Professcr,
University of California at San Francisco, Laneley
Porter Neuropsych,iatric Institute, Sam Francisco,
California.
Jane Halpern, M.D., ASPER, Office of Health and
Disability, UnirtedStates Department of Labor,
Washington, D.C.
Peatrix A. Ha mburg, M.D., Research Psychiatrist,
Laboratory of Development. Psychology, National
Institute of Mental Health, National Institutes of
Health, Bethesda, Maryiand.
Virginia C. Harris, M.D., Director, Maternal and
Child Health, Onondago County Health, . Department,
Syracuse, New York.
John H. Holbrook, M.D., Assistant Professor of
Internal Medicine, University of Utah Medical School,
Salt Lake City, Utah.
Stanley James, M.D., Professor of Pediatrics,
Ohstetrics, and Gynecology, College. of Physicians
and Surgeons, Columbia Presbyterian Medical Center,
New York, New York.
Hershel Jick, M.D., Roston Collaborative Drug
Surveillance Program, Boston University Medical
Center,. Waltham, Massachusetts.
Reese T. Jones, u.D.,. Professor of Psychiatry,
Departm ent. of Psychiatry, University of California at
San Francisco, Langley Porter Neuropsychiatric
Institute, San Francisco, California.
Philip Kimbel, k?.D., Head, Pulmonary Diseases
Section, Albert Einsteio-. Med.ical Center,
Philadelphia, Pennsylvania.
Jam W. Kuzma, Ph.D., Chairman and Professor of
Biostatistics, Department of Riostatistics and
Epidemiology, Loma Linda University, Loma Linda,
California. Abraham Liilienfeld, M.D., M.P.H., O.Sc.,llniversity
Distinguished Service Professor, Johns Hopkins School
of Hygiene and Public Health, Paltimore Maryland.
Harold A. M enkes, M.D., Associate Professor of
Medicine, Department of Medicine, Johns Hopkins
University, Paltim ore, Maryland,
Kenneth Moser, M.D., Professor of Medicine andd
xv
CONTENTS
INTRODUCTION ANJ Si.M1MARY ............................1
PART I
PATTERNS OF SMDKING AMOf•1G WOMEN AND MEN IN
THE UNITEDSTATES, 1900 .- 1979 .................... 15
The Rise of Cigarette Smoking:
1900-1950 ...................... 17
The Emergence of Filtertip
Cigarettes: 1951-1963 ......... 24
Increasing Public Health
Awareness: 1964-1979 .......... 25
Exposure to Cigarette Smoke -
Among Successive Birth .
Cohorts ........................ 31
Cigarette Smoking Among Vyomen....37
Summary .........................
PART Ii
BIOMEDICAL ASPECTS OF SMOKING
OVERALL MDRTALITY........................... ....53
Mortality Trends ..... .....................Epidemiological Studies................ ..58
American Cancer Society 25 -
State Study .................... 58
Swedish Study ....................60
Canadian Veterans Study ......... 60
Japanese Study of 29 Health Districts ...................... 60
British Doctors Study ........... 61
Framingham Heart Study.......... 61
British - Norwegian Migrant Study .......................... 62
Overall Mortality For Females-Cigarette
Smokers versus Non-Smokers ............ 63
Mortality Ratios................ .63
Amount Smoked and Age ........... 63
Duration of Smoking ............. 72
G
CJ
C~
m
~
CD
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CJI
xix
