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Smoking & Health - Part 2 of 9
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Related Documents:- 03685620-6854 Smoking & Health - Part 1 of 9
- 03685776-5930 Smoking & Health - Part 3 of 9
- 03685931-6085 Smoking & Health - Part 4 of 9
- 03686086-6240 Smoking & Health - Part 5 of 9
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- 03686706-6854 Smoking & Health - Part 9 of 9
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Document Images
SMOKING
and
HEALTH
a report of the Surgeon General
0
The Health Consequences of Smoking.
p The Behavioral Aspects of Smoking
p Education and' Prevention
DHEW Publication No (PHS) i 79-50066'
U.S. DEPARTMENT OF HEALTH; EDUCATION, AND WELFARE
Public Health Service
Office, of the Assistant Secretary, for Health
Office on Smoking and Health
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For, sale by the Superintendent of Documerrts, i.S. Gocernment Printing OtSce
Washington, D.C. 20q02
Stock Number 01 7, OMIp021g..0
THE SECRETARY'S FOREWORD
On January 11, 1964, the first Surgeon General''s Report on Smoking
and Health was published. It created' an instant-and jiustified-
worldwide reaction; For the reporta d'ocument of impeccable scientific
authority, established a frightening link between cigarette smoking
and several dlsabling or fatal diseases.
The report established that cigarette smoking is causally
related to lung cancer in men.
It revealed that cigarette smoking is directly related to il2ness
and death from heart disease and other ailments; thatt
cigarette smoking is the leading contributory cause of death
from chronic bronchitis and~ other lung disorders.
The report, in short, pronounced cigarette smoking a health
hazard of sufficient importance in the United States to:
warrant remedial'act'ion.
Today, 15 years after the original report, we publish a new Surgeon~
General's Report on Smoking and Health. This book is more than a
compendium of new data confirming the conclusions of the originall
report. For this document reveals, with dramatic clarity, that cigarette
smoking is even more dangerous-indeedy far more dangerous-than
was supposed in 1964.
The new report, for example, presents sobering information
about a subject not extensively treated in the 1964 report:
women and~ smoking. Among other things, the evidence
suggests that mothers who smoke during pregnancy face the
possibility of creating long-term, irreversible effects on their
babies: And as smoking levels among women go up, diseasee
and death rates go up also: lung cancer has inereased fivefold
among women since 1955. Women who smoke like men die like
men who smoke.
The report sheds new light on dramatically increased risks to
smokers exposed to certain occupational hazards. Workers in~
the asbestos, rubber, coal, textile, uranium, and chemical
industries, among others, face these risks.
And the new report, unlike its predecessor, takes up the
subject of smoking among children. The percentage of girls
aged' 12 to 14 who smoke, for example, has increased eightfold
since 1968. Among the age group 13 to 19, there are now 6
million regular smokers. One hundred~ thousand children
under 13 are regular smokers.
i
This document is significant for another reason It demolishes the
claims made by cigarette manufacturers and a few others fifteen years
ago and t'od'ay: that the scientific evidence was sketchy; that no link
between smoking and cancer was "proven." Those claims, empty then,
are utterly vacuous now. Fifteen years of additionall research
overwhelmingly ratify the original scientific indictment of smoking as
a contributor to disease and premature death. Ind'eed; even the
cigarette industry's own research from January 1964 throu& Decem-
ber 1973, at a cost of approximately $15 million, confirmed the lethal
dangers of cigarette smoking. Today there can be no doubt that
smoking is truly slow-motion suicide.
In truth, the attack uponi the scientific and' medical evidence about
smoking, is little more than an attack upon science itself: an attack
upon the epidemiological, clinical, and experimental research disci-
plines upon whichi these conclusions are: based. Like every attack upon
science by vested interests, fromi Aristotle's day to Galileo's to our own,
these attacks collapse of their own weight.
But why, the reader may nevertheless ask, should government
involve itself in an effort to broadcast these facts and to discourage
cigarette smoking?
Why, indeed? For one reason, because the consequences of smoking
are not simply personal and'privat'e. Those consequences, economic and
medical, affect not only the smoker, but every taxpayer.
When we consider two major nationall problems of health policy, we
find that cigarette smoking intensifies and complicates each one.
First among these problems is the spiraling cost of health care.
Health care costs nationwide now amount to $205 billion a; year-of
which the Federal Government pays $59 billion. Smoking accounts for
an estimated $5 to $8 billion in health care expenses; not to mention the
cost of lost productivity, wages, and absenteeism caused by smoking-
related illness; an annual cost estimated at $12 to $18 billion.
No person, given these staggering costs, can reasonably conclude
that smoking is simply a private concern; it is demonstrably a public
healthiproblem also.
A second major problem is that our health care system overempha-
sizes expensive medical technology and institutional care, while it
largely neglects preventive medicine and health promotion.
Certainly, if the government is to shift its health strategy toward
preventive rather than merely curative medicine, it cannot ignore
smoking. For snwking is the largest preventable cause of death in
America. When demographers look at death rates for diseases related
to cigarette smoking, they identify 84,000 deaths each year from lung
cancer, 22,000 deaths from other cancers, up to 225,000 deaths from
cardiovascular disease, and more than 19,000 deaths from chronic
pulmonary disease-every single one of them~ related to smoking. That
is why smoking is Public Health Enemy N'umber One in America.
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Having established the clear danger of smoking and the legitimacy
of smoking as a public health issue, however, a final question remains:
How much can government usefully do to publicize the hazards of
cigarette smoking; to encourage citizens to stop smoking-or not to
start?
Cigarette smoking, after all, is not like most other environmental
hazards: It cannot be curbed simply through~massive public and privatee
expenditures, as in the case of water pollution abatement, on which
$265 billion will be spent in the next 10 years. Cigarette smoking is not
subject to the same kinds of government regulation and' control that
are now used, for example, to check the emission of toxic substances
into the environment. These hazards can be dealt with through
straightforward programs of abatement and st'rict regulation. When it
comes to smoking, there is, of course, a role to be played by regulation
and by economic and other incent'ives. But in a free society, research
and; education must be the major tools of any public-health program to
deal with smoking.
So the stepped-up smoking-and~health program launched by the
Department of Healths Education, and Welfare a year ago is primarily
one of research, education, and persuasion. I described; it last year, in
testimony before the House Subcommittee on Health and! the.
Environment, in these words:
'Make no mistake, our efforts are to reduce smoking. But they are
efforts grounded in persuasion and information that appeal to the
common sense of our citizens. They are not efforts based~ on~ coercion
and scare tactics. I have the greatest empathy for the millions of
Americans who: want to stop smoking, but who find it very, very
difficult to do so...
'...If our citizens...are given all the facts from government, or other
sources, and still d'o not wish to give up: a personal habit, however
hazardous, then, except for protecting the rights of non-smokers, I
think government can properliy d'o no more.'
How successful~ can such efforts be? Quite successful', to judge from
the record:
Today, more than 30 million Americans are ex-smokers. This does
not include the number of people who, after consid'ering the risks,
chose never to take up the habit; they must also number in the millions.
The number of cigarettes consumed per person in the United States
has declined from 4,345 in 1963 to 3,965 in 1978. In fact, per capita
cigarette consumption this past year is at its lowest level in 20 years.
Thesefact's, without a doubt,arein~ large part due to efforts by
public health agencies and voluntary groups to inform the public about
the risks of smoking.
iu
These efforts are not mere publicity;, the record suggests that every
timegovernment and voluntary agencies have intensified their efforts
to: spotlight the risks of smoking, more smokers have given up: the
habit and more have decided not to take it up.
Moreover, we know from surveys of public opinion and attitudes
that the great majority of smokers-90 percent-have either tried to
quit smoking or would probably quit, if only they could find an
effective way to do so.
These people need help.
So; too, do millions of children an& young people who must have the
facts if they are to make a truly informed choice whether to smoke.
Indeed, it is children who are the main focus of our efforts to inform
and' persuade: It is not'hing short of a national tragedy that so much
death and disease are wrought by a powerful habit often taken up by
unsuspecting children1'ured by seductive multimillion dollar cigarette-
advertising campaigns.
This new Report of the Surgeon Generali typifies the Department's
approach to the issue of smoking and healtK It is based on scientific
resear& Its purpose is to provide facts. Its persuasive power is in the
weight cf the scientific evidence.
We set out t'o publish it for three reasons: First, we wished to bring
together new information on smoking and health which has accumulat-
ed in the 1'5 years since SurgeonGeneral Luther Terry released the
epochall report of 1964.
Second; we wishedi to extend the area of inquiry into smoking and
healthi beyond medicine into the fields of education and behavioral
science. For many of the: remaining unanswered questions about
smoking and health are in these latter fields. We have some evidence
for example, that women smokers have more trouble giving up,
smoking than men-but why? Some observers believe.t'hat women are
more concerned than men about gaining weight wheni they stop
smoking. But in fact we do not know; the answers to that and other
question& about smoking must be pursued through future behaviorali
research.
Third and finally, we wished to provide a firm base of knowledge on
which health agencies throughout this nation-and the world-can
build their efforts to reduce cigarette-related death and disability. For
the problem of cigarette smoking is not just domestic; it is worldwide.
Smokers in the United States consume 615 billion cigarettes a year;;
worldwide, the consumption of cigarettes approaches three trillion
each year.
This, thens is the report: a compendium of 22 scientific papers on
smoking and health, commissioned by the Surgeon General of the
Public Health~ Service, compiled by 12 agencies of the Depart'ment of
Health, Educat'ion,, and Welfare, and reviewed by scientists who are
recognized experts in their fields of inquiry. Thirteen of the papers
iv
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comprise a report on the health consequences of smoking, which the
Secretary of Health, Education, an6 Welfare is required~ by law to
submit to Congress each year. The remaining chapters deal with
behavioral aspects of smoking and with education and preventiom
This report is, in my judgment, a major contribution to knowledge
about smoking and health-and a major resource for physicians, public
health officials, educators and others who are concerned with
advancing the nation's health through a sound strategy of prevention:
Joseph A. Califano, Jr.
Secretary
Department of Health,
Education, and Welfare
January 11, 1979
v
On~ January 11, 1964, the Surgeon GeneralPs Advisory Committee on
Smoking and Health concluded: "Cigarette smoking is a health hazard
of sufficient importance in the United' States to warrant appropriate
remedialiaction."
Today, this report reinforces that major conclusion. It is backed up
by the weight of thousands of additional studies performed throughout
the world. Fifteen,years later, the scientific evidence on the health
hazards of cigarette smoking is overwhelhning.
The information in the health, consequences and! behaviorali parts of
this report has been brought together by 10 agencies of the United
States Public Health Scrvice: As will be seen, these agencies have
different research or regulatory missions but a common concern with
cigarette smoking as a contributor to illness, disability, and'death.
Since 1964, an estimated 30 million men and women have q;uit the
cigarette smoking habit. The prevalence of regular cigarette smoking
in the adult populationi has declined from approximately 42 percent to
33' percent (Appendix). Yet, in 1978, an estimated' 54 millioni men and
womeni smoked 615 billion cigarettes: Each year, the health damage
resulting from cigarette smoking costs this nation an estimated 27
billion dollars in medical care, absenteeism, decreased'work productivi-
ty, and accidents. A great fraction of these costs are borne by the
entire public-smokers and nonsmokers -through i health insurance,
disability pay.ments; and other private and taxpayer-supported! pro-
grams. In 1979, cigarette smoking is the single most important
preventable environmental factor contributing to illness, disability,
and death in the United'i States (Chapters 2 and 3).
This 1979 report describes our current knowledge of the health,
consequences of smoking;, the: behavioral aspects of smoking, and!
efforts in education and prevention. It presents strong conclusions
where they are warranted by the accumulated'i evidence. It provides
alternative working hypotheses when the available facts are not
sufficient to warrant conclusions. It suggests future lines of inquiry
where there are gaps in existing knowledge:
Adhering to this spirit of inquiry and recognizing the magnitude of
the public healthi problem, we must ask: What is our current
knowledge about "appropriate remedial action?" What scientific,
economic, and behaviorall facts are important for the design of public
policy toward cigarette smoking? What have we learned so far, and
where d'o we go from here?' To answ.er these questions, we must
confront three central facts: Individuals vary in their health riskss
associated with cigarette smoking. Individuals vary in their cigarette-
smoking behavior. The cigarette product itself i's changing.
vii
High Risk Populations
The adverse health effects of smoking vary considerably in their
nature and severity among individuals. They depend, for example, on
the duration and frequency of smoking, on the presence or absence of
concurrent illness or other environmental exposures, and on the
individual's, age and' sex. Some health~ effects are immediate, while
others may be delayed for years.
Most importantly, certaini individuals may be particularly prone to
these adverse health effects.
Women, youth, minorities, and' workers exposed to occupational
hazards in no way constitute an exhaustive list of. especially high risk
individuals. Every chapter in this report attempts to focus on
particular types of individuals of highest susceptibility. Cigarette
smoking acts synergistically with hypertension and elevated cholester-
ol to enhance the risk of developing coronary heart disease (Chapter 4):
Cigarette smoking may be a promoter or co-carcinogeni among those
individuals exposed to other cancer-causing agents (Chapter 5). It has
been suggested that there may be groups of smokers highly susceptible
to lung damage from cigarette smoke whose characteristics might be
detected by pulmonary function tests and histological studies or by the
presence of alpha-l-ant'itrypsin deficiency (Chapter 6). Those other risk
factors which may make maternal smoking more dangerous to the
fetus need' to be isolated, such as anemia, poor cardiac function,,
unfavorable age, and other socioeconomic factors (Chapter 8). Individ-
uals with rhinitis or asthma may in fact be more sensitive to the
nonspecific noxious effects of smoke (Chapter 10). Cigarette smoking
increases the risk of peripheral vascular disease in diabetics (Chapter
4).
Women and Smoking
The findings in the report have grave public health implications for
womem of all ages. Although the prevalence of cigarette smoking
among adult males has declined from approximately 53 percent in~ 1964
to 38 percent in 1978 (Appendix), the overall percentage of adult
female smokers remains virtually unchanged at about 30 percent
(Appendix). Cigarette smoking among younger women has increased,
particularly among teenage girls: The mortality rate from lung cancer
for women in 1978' was almost three times as high as in 1964, and the&
ratio of male to female mortality from lung cancer has decreased by
almost one-half (Chapter 5). Women who have smoking characteristics
similar to men experience overall mortality rates similar to men
(Chapter 2).
Cigarette smoking is a majior independent risk fact'or for fatal and
nonfatal heart attacks and' suddeni deathi in both men and women
(Chapter 4). The risk of heart attack is increased about tenfold in those
vut
women smokers who use estrogen-containing oral contraceptives
(Chapters 4 and 12).
The weight of evidence demonstrates that smoking during pregnan,
ey has,a significant adverse effect upon the well~being of the fetus and
the health~ of the newborn baby (Chapter 8).
There is abundant evidence that maternal smoking directly retards
the rate of fetal growth (Chapter 8) and increases the risk of
spontaneous abortion, of fetal d'eath,, and' of neonatal d'eath in
otherwise normall infants. More important, there is growing evidence
that children of smoking mothers may have rneasurable deficiencies in~
physical growth, intellectual development, and emotional development
that are independent of other known risk factors (Chapter 8). Children
of mothers who smoke during pregnancy do not cat& up with children
of nonsmoking mothers in various stages of development (Chapter 8).
Children and Teenagers
Smoking among teenage boys has remaine& virtually constant, and
among teenage girls it is actually increasing (Chapters 17, 18, and
Appendix). The average age of experimentation with cigarettes and
initiation of regular cigarette smoking has been decreasing (Chapter 17
and Appendix): Survey data suggest that teenage and early-youth
smoking habits are major determinants of lifelong cigarette consump-
tion. The mortality rates from all causes are significantly higher
among those who initiate smoking earlier in life (Chapter 2).
Evidence is accumulating that the health effects of smoking evolve
over a lifetime (Chapters 2, 3, 4, 5 and 6): Even when a morbid or fatat
consequence of smoking occurs in~ later life,, its antecedents may be
present even in childhood. For example, autopsy studies show that
cigarette smoking is associated with more severe and extensive
atherosclerosis of the aorta and coronary arteries (Chapter 4). Several
scientific questions have been raised about effects of smoking on the
severity of atherosclerosis in childhoodi and adolescence and the
premature development of adult forms of these lesions (Chapter 4).
Clinical, experimental, patholbgical, and epid'emiological studies in
humans and animals demonstrate that cigarette smoking produces
measurablie lung damage, even, in very young age groups (Chapter 6).
Young cigarette smokers, even those without respiratory symptoms,
have evidence of small airway dysfunction more frequently than
nonsmokers (Chapter 6). A number of recent studies have established a
higher prevalence of regular cough, phlegm production, wheezing, and
other respiratory symptoms in teenage and' young adult smokers ass
compared to nonsmokers (Chapter 6). The connection between~
pediatric respiratory illness and adult chronic respiratory disease has
been supported in prospective studies (Chapter 6).
Children and teenagers are susceptible in many ways to the effects
of others' smoking. Numerous research studies have found' a signifi+-
ix
