Tobacco Documents Online

Zp v The Health Consequences of Smoking 1 1977=1978 Prepublication copy: This copy is issued as a temporary_paper, preparatory to printing as a formal document. It omits the appendices and index which will appear in the final paper. Questions should be addressed the the Office on Smoking and Health, Rockville, Md. 20857 (301 - 443-1575). U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Office of the Assistant Secretary for Health Office on Smoking and Health

, S THE SECRETARY OF HEALTH. EDUCATION. AND WELFARE WASHINGTON. O. C. 20201 c The Honorable Thomas P. O'Neill Speaker of the House of Representatives Washington, D.C. 20515 !=!`"' Dear Mr. Speaker: . As required by Section 8(a) of the Public Health Cigarette Smoking ' Act of 1969, I am submitting the 1977-191S~revert on the health --consequences of smoking. The report includes the "Bibliography on Smoking and Health--1976," the "Bibliography on Smoking and Health-- 1977," and "The Health Consequences of Smoking, 1977-1978." The report -bears a 2-year designation in order to return the series to an annual timetable which was altered because of the time required for the clear- ance processing of the 1976 report. The Bibliographies are prepared -annually and routinely to reflect the new acquisitions to the smoking- and health data base which operates at a cost of $200,000.00 per year; the health consequences of smoking report, which is a review of this new current information and prepared specifically for Congress, this year cost $9,800.00. "The Health Consequences of Smoking, 1977-1978" includes recently pub- lished data from three classic prospective studies of the mortality re- sulting from cigarette smoking. These studies, involving almost one and a half million persons, continue to document excess mortality among smokers as compared to nonsmokers. This part of the report also includes data on the established risks of low birth weight and increased perinatal mortality for offspring of women who smoke during pregnancy. In addition, the new evidence is reviewed that shows not only a high rate of heart attacks among women who smoke cigarettes, but that this effect is particularly critical in women who use oral contraceptives. The data in this report indicate that former smokers show lower death rates than continuing smokers and within 10 to 15 years after quitting come close to the low rates of those who never smoked. O W ~ W M N Mr

r Page 2 - The Honorable Thomas P. O'Neill One study supports previous evidence that there is a partial solution to the health problem in the use of cigarettes with lower emissions of "tar" and nicotine. As a result of public demand and a responsive industry, there has been over recent years a continuing decline in the emissions of "tar" and nicotine in cigarettes in use. The data in this report and in previous annual reviews of the health consequences of smoking have established cigarette smoking as a habit re- sponsible for an overwhelming level of premature death and disability in this country. To reduce this preventable and costly mortality and morbidity, this Department recently announced a new antismoking program. The program is one of public education, regulation, and research with special emphasis on children, teenagers, and young women, and on occu- pations where smoking increases risks from occupational exposure. In undertaking this program, I have invited the cooperation of the major broadcast networks, State and local school officials, the major corporations of this Nation, State Governors and legislators, the Federal Trade Commis- sion, the Federal Communications Commission, the Civil Aeronautics Board, and others whose involvement and cooperation are crucial to the success of this program. In response to the evidence linking the combined use of oral contraceptives and cigarette smoking, the Food and Drug Admin- istration, Public Health Service, HEW, has recently required that a warning statement to that effect accompany oral contraceptives as they are dis- tributed to those who use them. To provide leadership and to coordinate this program, an Office on Smoking and Health has been established in the Office of the Assistant Secretary for Health. As one of its first tasks, this Office will coordinate the production of a comprehensive document which reviews not only the biomedical but also the behavioral and control data about smoking and its effects on health. The report will be submitted to Congress in January 1979. As the principal health officials of this government, the Surgeon General and I are committed to fulfilling our responsibilities to provide infor- mation and direction to permit American citizens to make genuinely free choices about smoking and their own health. In this regard and as I am required by P.L. 91-222 to make such legislative recommendations that I deem appropriate based on the scientific data about the impact of smoking

A 1. Page 3 - The Honorable Thomas P. O'Neill on health, I will submit within the year a legislative package which I hope will meet with your approval. With appropriate coordination of legislative action and occ+cram, we can solve this difficult and important e public health probl~ Sincerely,' Joseph A. Califano, Jr. Enclosures . Identical letter sent_to The Honorable Walter F. Mondale l :.b:~> ..p ...~~. _ . , _ ..~:~

a PREFACE . J : . .. ..1. . ~ l ~ . ~t' ! .. i ~~ . . . . ,. . . . . This tenth report to tiie Congress on the health consequences of smoking discusses the special problems incurred by women who smoke and presents - recently published overall mortality data on smoking ,~,., - ~.... i,:~Smoking was first recognized as a health problem in the 1930's, when a sharp increase was noted in lung cancer rates formen. No similar : 'Tincrease was noted for women at that time for several reasons. First, as a group, women did not start smoking when men did, since such behavior was socially unacceptable for women at that time. Consequently, until the last decade, there were insufficient numbers of women who had smoked • .`u'1 -.. ...a_. _ . ..... , - . _ . ~ : ., . , - . for a long enough period of time to provide the size population necessary ... ,, .. . .- _. ~_ . ._ ... . ~ . for meaningful research. . _ _ c rt ., . .. , _ :. A .... . . . . '. . :' : . . .. . . . r., ,_ _. • v _ _ In recent years, however, the same health risks to men as a result of . f~ . . ,_. .- .. -. _ - - smoking have been documented for women who smoke. These include cardio- vascular disease, lung cancer, cancer of other specific sites, bronchitis _.. . . : ~, - . . .. ~ ~ . . , _ . . . ~ and emphysema. These diseases occur among smokers at rates far greater than those of nonsmokers. Additionally, women have been found to incur unique risks for themselves and for their offspring. For example, women over 30 years of age who smoke and use oral contraceptives have substan- w ~ tially higher risks of myocardial infarction. Moreover, the offspring C~ C.~ of women who smoke during pregnancy face greater risks of perinatal ~ 00b mortality and low birth weight. Further understanding of the mechanisms li

involved in these health consequences continues to evolve. Three large prospective epidemiologic studies demonstrate that overall mortality rates for cigarette smokers are approximately 70 percent higher than those for nonsmokers. These studies also document a decrease in overall mortality rates for those who quit smoking, provided they were not ill at the time of cessation. There is about a 15 percent reduction in overall mortality risk for smokers of low "tar" and nicotine cigarettes (less than 17.6 mg. "tar" and less than 1.2 mg. nicotine) compared to those who smoke high "tar" and nicotine cigarettes (25.8-35.7 mg. "tar". and 2.0-2.7 mg.:nicotine). Several publications have become available since the last report to Congress which review the social, behavioral, legislative, and health issues re- lated to smoking. A recently published paper by Daniel Horn, Ph.D., as part of his work with the World Health Organization, discusses the major barriers to be overcome if further progress is to be made against the threat of smoking to health. A copy is report. included as Appendix A to this Two other publications of note include the U.S. Public Health .,;; Service's "Proceedings of the Third World Conference on Smoking and Health, 1975," DHEW Publication No. (NIH) 77-1413, 1977, Volumes I and II, and . ., .. - ~ the World Health Organization's "Smoking and Its Effects on Health," Technical Report Series No. 568, Switzerland, 1975. iii , fS,

e Table of Contents . Preparation of the Report and Acknowledgments CHAPTER 1. Smoking-Related Health Problems Unique to Women . .,. Introduction . . . . . . . . . . . . . . . . . . . , , Effects of Smoking on the Outcome of Pregnancy . . . . . , . . , , , -Smoking and Birth Weight ., ; ; ; ; , , ; , ; , ; ; ; ; ; , ," , . Smoking and Perinatal Mortality . . . . . . . . . . . . . . . . Long-Term Effects on Physical and Intellectual Development ... Carbon Monoxide and Carboxyhemoglobin Levels in Maternal and Fetal Circulation and the Possible Mechanisms-of Smoking-Effects -- - ori Pregnancy ... . : . . . . . . . . . . : : . .- . . . . . Smoking and Its Effects on Cardiovascular Disease Among Women Taking Oral Contraceptives . . . . . . . . . . . . . . . . . . . : : : .: : Summary of Smoking-Related Health Problems Unique to Women Effects of Cigarette Smoking on Lactation , , , , , , , , , , , , , , What Women Know About Smoking and Pregnancy , , , , , , , , , , , , , References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER 2. Smoking and Overall Mortality , , , , , , , , , , , , , , Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . Measuring Mortality . . . . . . . . . . . . . . . . . . . . . . . . . Mortality Ratios , , , , , , , , , , , , , , , , , , , , . Differences in Mortality Rates , , , , , , , , , , , , , , ~ ~ . . . Excess Deaths , , , , , , , , , , , , , , Life Expectancy . . . . . . . . . . . . . . . . . ... . . . . . Page

Description of the Studies , . . . . . . . . . . . . . . . . . . The American Cancer Society Study , , ; , , , , , , , , , , , , , The U . S . Veterans Study , , , , , , , , , , , , , , , , , , , , The British Doctors Study , , , ., , , , , , , , , , , Overall Mortality and Cigarette Smoking , , , , , , , , , , , , , Number of Cigarettes Smoked . , . . ', , , , , , , ,., Age --$egan Smoking . . . . . . . . . . . . . . . . . . . . . . . Inhalation Practice , , , , , , , , , , . . , "Tar" and Nicotine . . , ", , , , , , , , Ex-Smokers , . . . . . . . . . . . . .. : . .,. ,_ ~ Pipe and Cigar Smoking , , , , , , , , , , , , , , , , . , , , , , . Summary of Smoking and Overall Mortality References . I v . I rJ

f. CHAPTER 1 List of Figures Figure 1.-Risks of selected pregnancy complications for smoking and nonsmoking mothers, by period of gestational age at delivery for A, abruptio placentae, B, placenta previa, C, premature rupture of membranes (PROM) Figure 2.-Number of cigarettes normally smoked per day compared with Hb level at time of sampling in 93 pregnant women. mean and range of COHb levels for 129 nonsmokers Figure 3.-Oxyhemoglobin saturation curves of human maternal and fetal blood under control and steady-state conditions List of Tables Table 1.-Adjusted rates and F ratios for maternal smoking and _other_ important factors affecting birth weight, gestation, placental complications, and perinatal mortality Table 2.-Perinatal mortality and selected pregnancy maternal smoking levels Table 3.-Stillbirths according to cause during pregnancy complications, by in relation to maternal smoking Table 4.-Estimated annual mortality rate per 100,000 women from myocardial infarction and thromboembolism, by use of oral contraceptives, smoking habits, and age (in years) Table 5.-Estimated relative risks of nonfatal myocardial infarction, by use of oral contraceptives and cigarette smoking vi

CHAPTER 2 List of Figures Figure .-Annual probability of dying for current cigarette smokers, ex-smokers who quit less than 5 years ago, and never smokers, ages 55-64 Figure 2.-Annual probability of dying for current cigarette smokers, ex- smokers who quit 5-9 years ago, and never smokers, ages 55-64 Figure 3.-Annual probability of dying for current cigarette smokers, ex- smokers who quit 10-14 years ago, and never smokers, ages 55-64 Figure 4.-Annual probability of dying for current cigarette smokers, ex- smokers who quit more than 15 years ago, and ex-smokers, ages 55-64 List of Tables Table 1.-Age-adjusted mortality ratios for male cigarette smokers, by amount smoked, U.S. Veterans Study, 1954 cohort, 16-year follow- up Table 2.-Mortality ratios for cigarette smokers, by number of cigarettes smoked per day, British Doctors Study Table 3.-Mortality ratios for male cigarette smokers, by age and number of cigarettes smoked per day, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 4.-Age-adjusted mortality ratios for male cigarette smokers, by age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 5.-Age-adjusted mortality ratios for male cigarette smokers, by number of cigarettes smoked per day and age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up C Table 6.-Mortality ratios for cigarette smokers, by inhalation practice,L,? British Doctors Study Q ~ W ~ N Cd vii