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Table 7.-Mortality ratios for all cigarette smokers in two time periods, by sex and "tar" and nicotine (T/N) content in cigarettes smoked Table 8.-Mortality ratios for smokers of low "tar" and nicotine (T/N) cigarettes and nonsmokers in two time periods, by sex Table 9.-Mortality ratios for all cigarette smokers and nonsmokers in two time periods, by sex and "tar" and nicotine (T/N) content of cigarettes smoked Table 10.-Mortality ratios for ex-smokers who quit smoking on doctor's orders and for other reasons, by years since stopping, U.S. I Veterans Study, 1954 cohort, 16-year follow-up Table 11.-Mortality ratios for ex-smokers who quit smoking on doctor's orders and for other reasons, by number of cigarettes smoked per day, U.S. Veterans Study, 1954 cohort, 16-year follow-up ,Table 12.-Mortality ratios for ex-smokers who quit smoking on doctor's orders and for other reasons, by age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 13.-Mortality ratios for ex-smokers of cigarettes only, by years since stopping, number of cigarettes smoked per day, and age began smoking, U.S. Veterans Study, 16-year follow-up Table 14.-Mortality ratios for ex-smokers compared to nonsmokers, by number of years since stopping and age, British Doctors Study Table 15.-Age-adjusted mortality ratios for pipe-only, cigar-only, and cigarette-only smokers, U.S. Veterans Study, 1954 cohort, 16- year follow-up Table 16.-Age-adjusted mortality ratios for current cigar smokers, by .,number of cigars smoked per day, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 17.- Age-adjusted mortality ratios for current cigar smokers, by age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 18.-Age-adjusted mortality ratios for current cigar smokers, by number of cigars smoked per day and age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 19.-Age-adjusted mortality ratios for current pipe smokers, by number of pipefuls smoked per day, U.S. Veterans Study, 1954 cohort, 16-year follow-up viii !

.Table 20.-Age-adjusted mortality ratios for current pipe smokers by age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 21.-Age-adjusted mortality ratios for current pipe smokers, by number of pipefuls smoked per day and age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 22.-Age-adjusted mortality ratios for current cigar smokers, by use of other types of tobacco, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 23.-Age-adjusted mortality ratios for current pipe smokers, by use of other types of tobacco, U.S. Veterans Study, 1954 cohort, 16-year follow-up Table 24.-Age-adjusted mortality ratios for current cigarette smokers, by use of other types of tobacco, U.S. Veterans Study, 1954 cohort, - . . . .+ - .. .. - . . . . . ~. _..._ .J . .. J .. ~ _ . _ . =- -_: 16-year- ,follow-up Table 25.-Age-adjusted mortality ratios for all smokers, by type of tobacco used, British Doctors Study ix

;;_~:; PREPARATION OF THE REPORT AND ACKNOWLEDGMENTS Previous Reports Reviews of the scientific information linking smoking to health problems began in 1964 with the publication of Smoking and Health,-Report of the Advisory Committee to the Surgeon General of.the Public Health Service, subsequently referred to as't-he"Surgeon General's Report." Thereafter, Public Law 89-92 was passed requiring supplemental reports to Congress on 1. The Health Consequences of Smoking, A_ Public Health Service Review; 1967. „ this subject, and the following three reports were published: 2. The Health Consequences of Smoking, 1968 Supplement to the 1967 PHS Review. . The Health Consequences of Smoking, 1969 Supplement to the 1967 PHS Review. ~ Public Law 91-22 amended the previous law in April 1970 and required , a comprehensive review within 18 months, with annual reports to be sub- mitted thereafter. The result of this review was The Health Consequences of Smoking, A Report of the Surgeon General; 1971. Since then, the following annual reports on the health effects of smoking have been published: 1. The Health Consequences of Smoking, A Report of the Surgeon General, 1972. 2. The Health Conseguences of Smoking 1973. , O W 3. The Health Consequences of Smoking, 1974. ~ 4 C.W . The Health Consequences of Smoking, 1975. f.~ N x

., 5. The Health Consequences of Smoking, A Reference Edition, 1976. Each report since t:~e original "Surgeon General's Report" has reviewed the scientific literature relevant to the association between smoking and cardiovascular diseases, non-neoplastic bronchopulmonary diseases, and " cancer. Smoking as related to the following diseases and conditions has been reviewed periodically in these reports: Allergy (1972) Exercise Performance (1973) Harmful Constituents of Cigarette Smoke (1972) Noncancerous Oral Disease (1969) Overview: The Health Consequences of Smoking (1975) = Overview: The Health Consequences of Smoking (1976) Peptic Ulcer Disease (1_967,_1971, 19__721 1973) - - . ~ Pipe and Cigar Smoking (1973) Pregnancy (1967, 1969, 1971, 1972, 1973) Public Exposure to Air Pollution from Tobacco Smoke (1972, 1975) Tobacco Amblyopia (1971) The 1977-1978 Report This publication, The Health Consequences of Smoking, 1977-1978, contains the most recent data on the health effects of smoking unique to women and on the effects of smoking on overall mortality. Although emphasis is on the most recent data, research from earlier years is included where neces- _sary for clarity. The report was prepared by the staff of the National Clearinghouse for Smoking and Health, Public Health Service, in the following way: 1. The Technical Information Center of the Clearinghouse continually monitors and collects the scientific literature on the health effects of smoking by means of several established mechanisms: xi

M S. a. An information science corporation is under contract to extract articles on smoking and health from the scientific literature of the world. b. The National Library of Medicine, through the MEDLARS system, provides a monthly listing of articles on smoking and health. Articles not provided by the information science corporation are obtained for review. c. Staff members review current medical literature and identify .pertinent articles. 2. Initial drafts for the present report were prepared by the staff of the National Clearinghouse and sent to experts in the content area for review and conanent regarding the format, the appropriateness of the articles selected for discussion, and conclusions. The drafts were then revised by the Clearinghouse to incorporate these comments. The final drafts of the complete report were reviewed by the National Cancer Institute, the National Heart, Lung; and B1ood Institute, the National Institute of Environmental Health Sciences, the National Institute of Child Health and Human Development, and by additional experts both inside and outside the Public Health Service. xll

ACKNOWLEDGMENTS The National- Clearinghouse for Smoking and Health Director, Daniel Horn, Ph.D., "~r '.~t'~,.-' ... ..~.. . _...~~,., ... . ~. : - . ' ... : ~ . . -. ~ : .. . . was responsible for the preparation of this report. Medical Staff Director was"John°J.' Witte, M.D. The consulting and technical editors were Elvin E. Adams, M.D., and Susan J. Dillon, respectively. The Technical Information :,G .._ ..i, . _ .. .. . _ • . . "~Officer responsible for the literature collection was Donald R. Shopland. '=The professional staff has had the assistance and advice of the following experts in the scientific and technical . gratefully acknowledged: ~ fields whose contributions AUERBACH,'Oscar, M.D. - Senior Medical Investigator, Veterans istration Hospital, East Orange, New Jersey =- .i : are Admin- COHEN,! Lawrence S., M.D.'- Professor of Medicine, Chief of Cardiology, Yale_University, School of Medicine, New Haven, Connecticut FITZPATRICK, Mark J., M.D., M.P.H. - Fairhaven, Massachusetts :. . ...: r _ . _ , ,.. . _ . - ' , . _ . FRAZIER, Todd M. - Assistant Director, Center for Community Health and Medical Care, Harvard Medical School, Boston, Massachusetts _ _.r _ a .. .. .. KRETCHMER, Norman, M.D., Ph.D. - Director, National Institute of Child Health and Human Development, Bethesda, Maryland KRUMHOLZ, Richard A., M.D. - Medical Director, Institute of Respiratory Diseases, Kettering Medical Center, Kettering, Ohio LEVY, Robert I., M.D. - Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland MARINE, William M., M.D. - Professor and Chairman, Department of Preventive Medicine and Comprehensive Health Care, University of Colorado Medical Center, Denver, Colorado O W McMILLAN, Gardner C., M.D. - Associate Director for Etiology of ~ Arteriosclerosis and Hypertension, National Heart, Lung, and Blood W rnstitute, National Instibutes of Health, -Benesda; PlaryIand M W C1t . xiii

MEYER, Mary B. - Associate Professor, The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland NICHOLS, Ervin E., M.D. - Director, Practice Activities, American College of Obstetrics and Gynecology, Washington, D.C. PAFFENBARGER,.Ralph S.,;Jr., M.D. - Epidemiologist, Resource for;Cancer Epidemiology, San Francisco Bay Area, California State Department of Health, Berkeley, California L-,; PETERSON, William F., M.D. - Chairman, Department of Obstetrics and Gynecology, Washington Hospital Center, Washington, D.C. . PETTY, Thomas L., M.D. - Professor of Medicine and Head, Division of Pulmonary Medicine, University of Colorado Medical Center,:Denver, Colorado : RALL, David P., M.D., Ph.D. - Director, National Institute of Environ- mental Health Sciences, Research Triangle Park, North Carolina _ .. . ,... . . ,. , .,. . REINKE, William A., Ph.D. - Professor, Department of International Health, The Johns Hopkins University, Baltimore, Maryland „ RENZETTI, Attilio D., Jr., M.D. - Professor of Medicine and Head, Pulmonary Disease Division,.The University of Utah Medical Center, Salt Lake City, Utah SCHUMAN, Leonard M., M.D. - Professor and Head, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota ;, WYNDER, Ernest L., M.D. - President, American UPTON, Arthur C., M.D. - Director, National Cancer Institute, National Institutes of Health, Bethesda, Maryland - York City, New York xiv ...'.v: ~ Ll

CHAPTER 1 SMOKING-RELATED HEALTH PROBLEMS UNIQUE TO WOMEN _Eff ects 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 Eff ects on ,~. , ._._.. _ Pregnancy . .. , . . . Effects of Cigarette Smoking on Lactation . . . . . . . . . Oral CoAtracePtives Smoking and Its Effects on Cardiovascular Disease Among Women Taking What-Women Know About Smoking and Pregnancy Summary of Smoking-Related Health Problems Unique to Women Page

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 ~OHb level at time of sampling in 93 pregnant women. = mean and range of COHb levels for 129 nonsmokers wi th - 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,' placerital complications, and perinatal mortality Table 2.-Perinatal mortality and selected pregnancy complications, maternal smoking levels y Table 3.-Stillbirths according to cause in relation to maternal smoking during pregnancy ; ,..._•. , ~ : . : •. . , • . ~ 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 2 n h)

10 SMOKING-RELATED HEALTH PROBLEMS UNIQUE TO WOMEN ;x ; ... . .: . - .: CHAPTER 1 INTRODUCTION Smoking habits and attitudes among women and teenage girls have differed in the past from the habits and attitudes among men:4x and teenage boys. .,,.. _ . 'Women tended to smoke fewer cigarettes, were less likely to inhale, and were more likely to smoke low "tar"and-nicotink and filter-tipped brands. Surveys-have indicated, however,-that the smoking habits of women are becoming ~.1. '7.;' _ . _ - . : . . - . . - - - . . . . . . . . ..~' .. . . . . _ . ... . . - . . . more like men's. Women are taking up the ha~it at an earlier age and have -,; V.. ; -- - --------------- become ~'leaVier- sino-ker - s . Ttiis T18s mSde tfieill mote kulnerable not only to lung cancer and other smoking-related_diseases,;but also to specific health problems that are unique to their sex. For example, research on the'relationship between cigarette smoking and the outcome of pregnancy has established that there are definite risks to both the fetus and the mother associated with cigarette smoking during pregnancy. Moreover, women who`use oral contraceptives are-at greater risk of.cardiovascular disease _. ~- .- .. .. _ if they-smoke cigarettes. There is also evidence that nicotine is present in the~-breast-milk of lactating"inothers who smoke. 2he following is a . _, . ...- . -.. .,.._ review of the current information on these and other health consequences of smoking unique to women. EFFECTS OF THE O ---ti'TCO-M-E OF -- --------PREGNANCY --- --- SMOKING ON There are definite health risks associated with smoking and pregnancy, w including effects on birth weight, perinatal mortality, 3 -111 and long-term C9 . w cn w c~