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i V. J f ~ i u Public Health Service Health Services and hzlentaJ' Health Administration °'~~~ :~J'`~"W a U~.S~~. DEPARTMENT OF ~ HEALTH, EDUCATION, AND~, W'ELFA~~F(E~ Y 0 f'. f t* K k. ~'~`ry+C:

The Health Consecluences of Smaking A Report of the Surgeon General: 1972 U.S: DEPAR7JIVIENT' OF HEALTH,, EDUCATION,, AND, W'ELFARE' i Public Health Service Health Services and Mental Health Administration For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402'-Price 70: cents. Stbck Number 1723-0051

Honorable Carl Allbert. Speaker of the Hiouse of Representatives Washington, D.C. 205,15 Dear Mr. Speaker : Ehclosed is the 1972' report on the healthi consequences of snnoking„ ascalledforbySection8'(a), ofthePubllicHealth Cigarette Smoking, Act of 1969. As you will see, it continues and strengthens the find- ings of previous Public Health Service reports that cigarette srn:oking, is a hazard' to the health of the American peopl'e.. Under this Act„ I am also required to submit to youl suchi recom- menddtion& for legislation as I d'eem~ appropriate. As you know,,ithas long,been, the position of this Department that an adequate health warning; shouldl appear in cigarette advertise- ment& along with listings of "tar" and nicotine. We are: in support of the current efforts of the Federal'Il'rade Commission to bring this about through the exercise of its regulatory powers. Should, these efforts fail, however, we would return to our previous reeornmenda- tions that this should be accornplished through legisl~ative action. With kindest regards, Sincerely, Elliot L. Richardson Secretary

Preface Six times since 1964, the Public Health Service has issued formall reviews of the scientific evidence which links cigarette smoking to disease and premature death. Eaeh successive review, including this one, has served to:conffrm and strengthen the conclusion of the: 1!19'64 Report, that eigarettes are a major cause of death and disease. In the first three chapters of this report, the relationships be- tween cigarette smoking and cancer, cardiovascular disease, and non~-neoplastic bronchopulmonary disease are reviewed and evi~ dence is presented whichi helps develop our understanding of' thee mechanisms which are involved in~ these relationships. In the finall three chapters; information is presented on public exposure to, air polluti'on, from tobacco, on the relationship between tobacco and allergy, and on the harmful constituents whichi are found in ciga- rette smoke. In the past few years, millions of Americans have stopped smok- ing because they have persuadedl themselves that it is in their own self-interest to do so ; we must continue to encourage cessation as the only certain way to protect both the individuall and society frorn the harmful effects of' smok:ing. We must also, however,, work to- wards reducing the dangers ofl smoking for those who have notl quit by develbping less hazardous cigarettes and encouraging less hazardous ways of smoking. The chapter which discusses the harmful constituents of smoke is a useful statement, of our current knowledge in this field ; it should interest not only research scien- tists but those who are concerned with public education and public policy. Research in smoking, and health continues, as this report shows,, both in this country and abroad and' under both public and private auspices ;, furthermore, the range of this research is widening as the significance of cigarette smoking as apublic health problem becomes more apparent.Iln establishing the present series of reports, first under Public Law 89-92' and now under Public Law 91-222, the Congress has givenius a means of encouraging the research we need and of building a better understanding of the problem. JIESSE'L. S'11EINFELD; 1VII.D.Surgean, General Q ~ V ~ ~ a1 CJt ~'

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Tabi e of Contents~ Page Letter of Transmittal .................................. iii PREPARATION OF THE REPORT ANDi ACKNOWLEDGMENTS .......................... Chapter 1.~ Introductioni and Summary .............. Chapter 2. Cardiovascular Diseases ............... v iix 11 Chapter 3. 1*Ton-neoplasticBronchopulmonary Diseases ... 35, Chapter 4. Cancer ................................... 57' Chapter 5'., Pregnancy .............................. 81 Chapter 6. Gastrointestinal Disorders ................... 95 . Chapter 7. Allergy .................................. 101 Chapter 8. Public Exposure to, Air Pollution from, Tobacco Sinoke .......................... 1M Chapter 9. Harmful Constituents of Cigarette Smoke ..... 139 Index ................................................. 151

Preparation of, the Report anid, Acknowllsdgments "'Srnoking, and Health. Report of the Advisory Committee to the Surgeon General of'the Publi'c Health Service"* was published ini 1964. The following dbcuments were subsequently published as re- views of the medical literature as called for by Public Law 89-92. 1. "The Health Consequences of Smoking, A Public Health Serv- ice R'eview : 19'67"* * 2. "The Health Consequences of Smoking, 11968 Supplement to the 1967 PHS' Review"* * 3. "`The Health Consequences of' Smoking, 1969 Slzpplement to the 1967 PHS R'eview"**' These documents reviewed the medicall literature which had been published since the original Surgeon General's Report. The format of publishing a supplement t'o a supplement became unwieldy, par- iews ticularly in the light of the lack of availability of previous revs to the general public. Therefore, when P.L. 91-222 was signed intb law on April 1, 1970, calling for an 18-month interval between the previous report and the new report, the entire field was reviewed with~ an emphasis on the most recent additions to the literature.. The product of this review was :"The Health Consequences of Smoking, A Report of the Surgeoni Generall: 1971."* * The present document, "The Health, Cansequencesof Smoking, A. Report of' the Surgeon General : L972,"' includes a review of' the literature which has been published since the 1971 Report was completed. It also includes an evaluation of the state of knowled'ge in three areas which have not been previously reviewed in these reports : allergy and tobacco, public exposure to air pollutioni frorn tobaccoisrnoke; and harmful constituents of cigarette smoke. The Nationall Clearinghouse for Sinoking and, Health has the responsibility for the continuous monitoring, and! compilation of the medical literature on the health consequences of smoking and for the preparation of this dbcument. This is accomplished through sev- eral mecha.n2sms : • Referred too in this~ manuscript as~s the~.Surgeon General's~~. Report~L Referredd to~ in, this manuscripbt as ~~. "The,Hea]th Cansequences~~ of'. Smoking; " iz

11. An information science corporation is on contract to extract articles on smoking and health from~ the medical literature of' the worldl This organization provides a semi~-monthly acces- sions list wiith: abstracts and copies of the various articles. Translations are called for as needed. Articles are classified according to subject and filed by a sei:ies of code words and phrases. 2. The National Library of' Medicine; through the Medlars sysr tem, sends the National Clearinghouse for Stnoking and Health a monthly listing of artieles in the smoking and health area, These are reviewed, and articles not identified by the information science corporation are ordered. 3. Staff members review current medicall literature and identify pertinent articles. Initial drafts of the present review were prepared by the staff' direetor„ assistant staff director, and' consulting, editors. The firstdrafts of the individual chapters were sent to experts for review, criticism, and comment with respect to ~ the articles reviewed, arti- cles not included, and conclusions. The drafts were then revisedd until they met with the general approval of the reviewers. The final ftafts were reviewed as a whole by the Director of the Nationall Clearinghouse for Sinoking,andiHealth, the Director of'the National. Cancer Institute, the Director of the Nlationali Heart and Lung Ihstitute, the Director of the I'dational! Institute of Environmental H'ealth: Sciences, and by six additional experts both within and out- side of the Public Healtli S'ervice: Acknowledgment's. The Nat'ional Clearinghouse for Smoking and' Healthy Daniel Horn, Ph. D!, Director, was responsible for the preparation of this report. Staff Director for the report was John H. Holbrook, M.D., and Assistant S!taffDirector wa& Elvin E., Adams;, M.D!, D'aniel!, P.. Asnes, M.D., and David G. Cook,, M.D., were Consulting, Editors, The professional staff has hadithe assistance and advice of a num- ber of'experts in the scientific andl technical fields, both in and out- side of'the Government. Their contributions are gratefully acknowl- edged. Special thanks are due the folIowing:. Arrneesorr„wiLLtpnrt H., M.D: Chief; Pulmonary Section, School of Medicine, University of Louisville, Louisville;, Kentucky. ANTHOrrIsErr, NICHOLAS R.,,M.D., Ph: D-Associate Professor, Department of' Experimental, Medicine, McGill' University, Montreal, Quebec, Canada. x L-'~

i ;tractre of cces- pcles. ~iftied' I and i I I ~ sys- and and ealth y the staff i first view, ; arti- ivised I final, tronal ~ional Lung lental out- panilei Daniel >f this 1VT.ID:, iel P. rs.. num- out- now,l'r dicine, ent of AuERBACHy OseAR', hiLD.-Senior Medical Investigator, Veterans Administra- tion Hospital,,East Orange, New Jersey. A-i'sKS, STEPHEN M., M.D., Di'rector, Cardiopulmonary Laboratory,,Saint Vin- cent's Hbspital and Medical Center of New York, New York, New York. BAKER, CARL G., M.D.-Director, National! Cancer Institute, National Institutes of' Health, Bethesda, Marylandi BtxG, RICHARD J., M1D:-Proflessor of Medicine, University of' Southern Cali- fornia, Huntington~ Memorial Hospital, Pasadena, California. Ba¢K, FftEn G., Ph. D'.-Director; Orchard Park Laboratories, Roswell' Park Memorial, Institute, Orchard' Park, New York., BOREN, HbuLis G., M.D: Chief, Pulmonary Disease Seetions The Medical Col'* lege of Wisconsinj , Wood Veterans Administration Hospital, M'2lkvaukee,. W isconsim BOUTWELL, ROSWELL K., M.D: Professor of Oncology, McArdle Laboratory for Cancer Research, University of Wisconsin, Madison, Wisconsin. COOPER, THEODORE, M.D.-Director, National Heart and Lung Institute, Na- tional Institutes ofl Healtlhy Bethesda:, Maryland. CoxINFrELn„ JeEtomE--Research Professor of Biostatistics, Graduate School of Public Health;, University of Pittsburgh, Biostatistics Project, Bethesda, Maryland. EPSTEIN, FREDEarCi[ HL, M.D. DirectorandlProfessoroflEpidemiology,,Sehool. of' Public Health„ University of Michigan, Ann Arbor, Michigan. FALK, HANS L.,,P'h. D-Associate Director for Program, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina. FAgR; RICHARD, M:D.-Head, Department of Allergy and, Clinical, Immunology, Nationall Jewish Hospital and Research Center, Denver, Colbrado, FERRIs, BENJAMIN G., J[t.,, M.D.-Professor of Environmental Health, and. Safety, School of Public Heaithy Harvard University, Bostony Massachusetts. FTtvKLEA, JOHN F.,, M.D.-Acting Director„ Division of Effects Research` Na- tional Environmental Research Cent'er;, Research Triangle Park, Niorth Carolina. FITZPATRICK, MARK J., M.D: Obstetrician, Perinatal Biology and Infant Mor- tality Branch, National Institute of' Child Health and Human Development,, National, Institutes of Health, Bethesda, Maryland. FxAZtER„ToDD M'.-Assistant,Director, Harvard Center for Community Health, and Medical Care, S'chooll of' Public Healthy, Harvard University, Boston, Massachusetts. FRESTON, JAMES; 1GI.D.-Associate Professor of Medicine, Head, Division of! Gastroenterology, Uhtiversity of Utah Medical, School, Salt: Lake City,, Utah. GocnsMiTx„JoHN R.,,M.D,-Head, Environmental Epidemiology Unit„Bureau of' Occupational Health and Environmental Epidemiology, California, State Department of'Public H'ealth,, Berkeley,, California. HANNA, MICHAEL G'., JR., Ph. D.-Director, I:mmunol'ogy, of' Carcinogenesis Program, Oak Ridge National Laboratory, Oak Ridge, Tennessee. HARKAvY,, JOSEPH, 1VLD. Clinicall Professor of Medicine (Emeritus), The Mount Sinai Medical School of the University of New York, New York, New York. HIGGINS, IlpN T. '1;.,,M.D.-Professor of Epidemiology, School of'Public Heaith, University of' M,icfiigan, Ann Arbor;,lVTichigan. HOFFMANN, DiK^rRacx;, Ph. D:-Chief,, Division of' Environmental Carcino- genesis„ American Health Foundationy, New York, New York. KELLER, A,rmnREw Z,, D:M.D;-Chief, Research in Geographic Epidemiology, Veterans Administrationi Central Office, Wasfiington~ D.C~ xi

KIRSrtER„JosEPH B, M.D., Ph. D.-Chief of Staff and Deputy Dean for Medical Affairs, The Pritzker School of Medicine, University of Chicago Hospitals and Clinics, Chicago, Illfinois: Ko[sYE; ALBERT C:, JR., M.D:, J.D.-Deputy Directbr, Bureau of Foods, Food and Drug, Administration, U:S'. Depart'rnent of' Health„ Education, and Well- ; fare, Washington„ D.C. i Ka.UwIHOLZ, RICHARD A., 1VI.D.-Medical, Director;, Institute of Respiratory Diseases, Kettering Medical Center;, Kettering, Qhio.. LEtveatvm,, CLAUDE JL M., 11S1D -Associate Director f'or Lung, Programs, Na- tionall Heartl and Lung Institut'e, National Institutes of Health, Bethesda,, Maryland. LIEBOW, AVESILL A., M.D.-Professor and Chairman, Department of Pathology, 1 University of California (San Diego), Lai Jblla, Calif'ornia. ~ LILIENFELD;, ABRAHAM, M.D.-Professor and, Chairman, Department of Epide- miology,, School, of'Hygiene and Public Health, The Johns Hopkins University, ~ B'altimore; Maryland., LowE.LI;,, Ffi;nNCis C., 1Vf.D. Chief, Allergy Unit, Massachusetts General Hos- pital, Boston, Massachusetts. MCLEAN, Ross, M.D.-Professor of Medicine, B'owman, Gray School ofl Medi- cine, Wake Forest University, Winston, Salem,, North Carolina. !' MCMILLANS, GARDNER C., M.D.-Chief, Arteriosclerotic Disease Branch,, Na- tional' Heart and Lung Institut'e, National Institutes of Health, Bethesda, ~ Maryland. i MACMAHON, BxIArr„M.Di-Professor of Epidemiology, School of'PublicHealth, j ~ I Harvard University, Boston, Massachusetts. MEYER, MARY B., MRs.-Assistant Professor ofl Epidemiology,, The Johns i' Hopkins University, Baltlimore,, Maryland. i, MITCHELL, ROGER S., MLD-Chief of Staff, Veterans Administration Hospital, ~, Denver, Colbrado~ + MURPHY, EDMOND A., M.D'., Sc. D.-Associate Professor of Medicine and Bio- l statistics, The Johns~ Hopkins Hospital, Baltimore, Maryland. ~ NervaLL,, VAUN A., M.D:-Chief,, Health, Effects Branch, Environmental Pro- tection Agency, Washington, D.C. PAFFENBARGER, RAcPH S., Jit., 1VI.D-Chief, Epidemiology Seetlion,, Bureau of Adult Health, and Chronic Diseases, California State Department of Public Health,, Berkeley;C'alifornia., PARKER, CHARr.ES' W'., M.D.-PYofessor of Internall Medicine, Division of Im- munology, Washington University Medical School, St. Louis, Missouri. PETERS, JpHN M., M.D.-Associate Professor of Occupational Medieine,, School of'Public Health, Harvard University,,Bostbn, Massachusetts. PETEesoN, WILLIAM F., MID-Chairman, DepaR•tment, of Obstetrics and Gyne- cology, Washington Hospital! Center, Washington, D'.C. PET•rs, THOivcAS'L.,, M.D.-Associate Professor of Medicine and Head, Divi'sion of Pulmonary Diseases, University of Colorado Medical Center, Denver, Colorad'o. Ra:el:,, DAVID P., M.D.-Director, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina. REruzErrTI, ATTItrIO: D:, JR., M.D.-Professor of' Medicine, Pulmonary Disease Divisions University of Utah Medical Center„ Salt Lake City, Utah,. Rosirrs, MosTOrt-Chief of Study, Design„and Analysis Staff,,Regional Medical Programs Service,, Healtihi Services andl Mental Health Administlration, Rockville,, MaryUand. SaFFloTrrI, UMBERTO, M.D.-Associatle Scientific Director for Carcinogenesis, Etiology National Cancer Institute, National, Institutes of H,eaith,, Bethesda, Maryland. ~ xii