The Health Consequences of Smoking A Public Health Service Review] 670000

Lorillard

The Health Consequences of Smoking A Public Health Service Review] 670000

Date: 19670000/P
Length: 213 pages
03764749-03764961
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Fields

Author

Stewart, W.H.

Area

LEGAL DEPT FILE ROOM

Type

PSCI, SCIENTIFIC PUBLICATION

BIBL, BIBLIOGRAPHY

CHAR, CHART/GRAPH

LIST, LIST

Site

N14

Request

I1-001

I1-003

I1-005

Named Person

Abinanti, F.R.

Albany

Ames, B.N.

Anderson

Arend, W.P.

Auerbach, O.

Axelrod, D.

Ayres, S.M.

Ayres, W.R.

Ballenger, J.J.

Bates

Becker

Berendes, H.W.

Berg, G.W.

Berliner, R.

Bing, R.J.

Bless, S.R.

Bock

Boren, H.

Borhani

Carrol, B.E.

Cederlof

Chadwick, D.R.

Chandler

Clark

Clarke, R.F.

Coates

Cook

Cornfield

Corwin, E.

Delapuente, J.L.

Deykin, D.

Dobbs, G.

Doll

Dorn, H.F.

Doyle, J.

Eastman, N.J.

Epstein, F.H.

Erlich, S.P., J.R.

Evans, R.

Falk, H.L.

Ferris, B.G., J.R.

Fox, B.H.

Fox, S.M.

Framingham

Friedman

Gittlesohn, A.

Gold, R.J.

Graham

Haenszel, W.M.

Halperin, M.

Hammond, E.C.

Haskell, W.L.

Hayes, R.

Heinzelman, F.

Hernandez

Hess, C.B.

Higgins, Iit

Hill

Hoffmann, D.

Holland

Horn, D.

Huhti

Hutchings, R.S.

Imboden, C.A.

Iskrant, A.P.

Jansson

Jenkins

Kahn

Kannel, W.B.

Kenner, H.

Kerr

King

Kiryu

Kolbye, A.C., J.R.

Kolbye, S.M.

Kotin, P.

Krueger, D.E.

Krumholz

Kumar

Kuratsune

Landau, E.

Legator, M.S.

Lemaistre, C.A.

Lilienfeld, A.

Loncin, H.

Loudon, R.G.

Lundman

Macmahon

Marland, R.E.

Mclean, R.

Moore

Morrison, B.H.

Mount, F.W.

Murphy, E.A.

Neurath

Peters

Peterson, W.F.

Petty

Petty, T.L.

Reid

Robbins

Robins, M.

Rockey

Rosenman

Ross, W.L.

Russek

Schor

Schuman, L.M.

Schwartz, J.T.

Shear, M.J.

Sidel, J.S.

Steele

Steinke, W.

Strong, J.

Surgeon General

Syme

Thom, T.J.

Truett

Underwood, P.

Waingrow, S.

Weinblatt

Wember, D.G.

Westura, E.

White, E.L.

Wicken

Woolsey, T.D.

Wynder, E.

Yarmolinsky, M.

Yerushalmy

Zukel, W.J.

Document File

03763512/03766002/S H Re 1979 Surgeon General S Report.

Date Loaded

09 May 2000

Named Organization

American Cancer Society

American Thoracic Society

Andrews Air Force Base

British Medical Research Council

Bureau of Disease Prevention + Envi

Emory Univ

Evanston Hospital

FDA, Food and Drug Administration

Ftc, Federal Trade Commission

Harvard Medical School

Harvard Univ

Johns Hopkins Hospital

Johns Hopkins Univ

La State Univ

National Health Survey

Natl Center for Chronic Disease Con

Natl Center for Urban + Industrial

Natl Center for Air Pollution Contr

Natl Center for Health Statistics

Natl Clearinghouse for Smoking + He

Natl Environmental Health Sciences

Natl Heart Inst

Natl Inst of Allergy + Infectious D

Natl Inst of Neurological Diseases

NCI, Natl Cancer Inst

NIH, Natl Inst of Health

Saint Vincents Hospital + Medical C

Sgc, Surgeon General's (Advisory) Comm

Ski, Sloan-Kettering Inst

Tobacco Industry Research Council O

Union Univ

Univ of Co

Univ of Mi

Univ of Mn

Univ of Pa

Univ of SC

Univ of Tx

Univ of Wi

Veterans Administration Hospital

Wayne State Univ

Who, World Health Org

Litigation

Fali/Produced

Author (Organization)

Hew, Dept of Health Education and Welfare

Public Health Service

US Government Printing Office

Characteristic

MARG, MARGINALIA

Master ID

03764103/6002
Related Documents:

UCSF Legacy ID

hun13c00

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I s a E THE NATURE OF THIS REPORT . ... ......... .:...,'4St".-.-....,..,.- This report which provides a summary of current information on the health consequences of smoking, is based on the review of the research reports which have become available since the study of the Surgeon General's Advisory Committee was released. Public Health Service staff members consulted the literature and requested additional infor- mation or interpretations of the published data from the research scientists when needed. During this review a complete bibliography, containing some 5,700 citations, was compiled; it is now in manu- script form and will be published shortly (19). The advice and comments of experts within the Public Health Serv- ice, particularly the Bureau of Disease Prevention and Environmental Control and the National Institutes of Health, as well as of specialists outside the Public Health Service, were solicited especially on matters involving judgment and evaluation. , ... ,. . ., . . . The general criteria used by the Surgeon General's Committee have been followed. First, epidemiological data were evaluated to determine whether an association exists. In judging the significance of the as- sociation, its consistency, strength, specificity, temporll relationship, and coherence were utilized. The convergence of evidence from animal experiments, clinical and autopsy studies, and population studies re- mains the essential basis for evaluation of the significance of the associations identified. . . . . . This report presents, under the following headings, the major fmd- ings of research studies published in the past 3 to 4 years: 1. Smoking and Overall Mortality. 2. Smoking and Overall Morbidity. 3. Smoking and Cardiovascular Diseases. -. 4. Smoking and Chronic Bronchopulmonary Diseases (Non-neo- plastic). . 5. Smoking and Cancer. 6. Other Conditions and Research Areas. . Each of these sections is introduced by pertinent conclusions from the Surgeon General's 1964 Report, which are followed by discussion and conclusions of the preaent study. . . . ~..; sK , . . 4k » x

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the time when there was also a substantial drop in cigarette smoking among physicians in general, and during the time that lung cancer There are no adequate data to evaluate the benefit of reductions in exposure that are more modest than those achieved by complete cessa- tion, although it seems reasonable to assume that a substantial reduc- tion in exposure is likely to be accompanied by some reduction in risk tion of risk compared to those who continue to smoke. tality for those who give up smoking as also reflecting a direct altera- case can now be made for interpreting reduced rates of overall mor- These findings are shown in Table 2, which has been derived from Doll's report (7). The lung cancer death rate among men in England and Wales increased from 1.49 per 1,000 in the period 1954-57 to 1.86 per 1,000 in the period 1962-64, a rise of 25 percent. At the same time, the lung cancer death rate for British physicians dropped from 1.09 per 1,000 in the first period to 0.76 per 1,000 in the second period, a reduction of 30 percent. This reduction in death rates from lung can- cer among all physicians is larger than would have been anticipated from examining only the experience of those physicians who had stopped smoking before the study began and indicates that the ex- perience of ex-smokers in prospective studies probably understates the benefits of giving up smoking. With these findings the case for cigarette smoking as the principal cause of lung cancer is overwhelming. The reduction of rates eaperi- enced in ea-smokers as compared with continuing smokers is clearly shown in the case of lung cancer to be a reflection of a significant change in risk. Since the concern that selective bias might have ac- counted for the earlier findings has been contraindicated, a stronger length of the cessation period increases. as the rate of smoking among British physicians decreases and the report by Doll (7) suggests that this trend is becoming more marked as against another population in which it is not common. A more recent the effect of giving up smoking is judged by the mortality results in an entire population in which the giving up of smoking is common rates were rising in the male population of Great Britain. This situa- tion is not unlike that of a controlled cessation experiment in which relative to those who do not reduce their exposure.

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Ixe pl ts rs Smoking and OveraHl Mortality QviONCLIISIONSOFTHE SIIROl GENIIIhLiS. 1961 R$PORT CIGARETTE smoking is associated witk a 70-percent increase in the age-specific death rates of males, and to a lesser extent with in- creased death rates of females. The tot'al number of excess deaths causally related to cigarettee smoking in the U.S, population cannot be accurately estimated« In view of the continuing andmounting evi- dence from many sources, it is the judgment ofl the Committee that cigarette smoking contributes substantiallly to mortality from, certain speeifie diseases and to the overall death rate. In general, the greater the number of cigarettes smoked daily, the higher the dhath rate. For men. who smoke fewer than 10~cigarettes a day,. according to the seven prospective studies, the death rate from all causes is about 40 percent higher than for nonsmokers. For those who smoke from 10 to 19 cigarettes a day,, it is about 70 percenthigher than for nonsmokers; f'orr those whoo smoke 20 to39 a day, 90 percent higher; and for those who smoke 40.or more, it is 120 percent higher. Cigarette smokers who stopped smoking,before enrolling in the seven studies have adeath rate about 40 percent higher than non- smokers, as against 70 percent higher for current cigarette smokers. Men who began smoking before age 20 have a substantially higher death rate than those who began after age 25. Compared.with non- smokers, the mortality risk of cigarette smokers, after adjustments for differences in age, increases with duration of smoking (number of years), andl is higher in those who stopped after age 55 than for those who stopped at an earlier age.. In two studies which recorded the degree of inhalation, the mortality ratio for a.given amount of smoking was greater for inhalers than for noninhalers. . The ratio of death rates of smokers to that of nonsmokers is highest at the earlier ages. (40-50) represented in.these studies, and decPiness with increasingg age.. - Possible relationships of death rates to other forms. of tobacco: use were also investigated ''. The death~ rates for men smoking less than 5 cigars a day are about the same as for nonsmokers. Fbr men smoking more than 5 cigars daily death rates are slightly higher. There is.some indication: that these kigher death rates. occur primarlly in menn who have been smoking more than 30 years and', who. inhalethe smoke to sorn e dhgnee. The death rates for pipe smokers are little. ifat all higher than for nonsmokerseven for men who smoke10 or more pipefuls a day and for men who have smoked pipes more than 30 years,, 271~394 0--67-2

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03y64797

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'es, of'; ?er er- ,nd he or .ion !ars ina, ble at it"' ish ent lie. ers had a comparatively lower rate,. which was still 36 percent above the rate for nonsmokers "' * Men smoking combinations of ciga- ret'tes plus cigars and/or pipe also had elevated death rates for overalll mortality,but these were not elevated to the same eatent as those of men smoking only cigarettes. "The death rates for overall mortality of pipe smokers and cigar smokers were not appreciably different from those of nonsmokers; "For cigarette: smokers as compared to nonsmokers, overall mor- tality ratios were elevated after 5 years of smoking at any t'ime in their life and remained elevated as.long as they continued to smoke cigarettes.. "Mal'e current cigarette smokers who imhalerl had a death rate for overall mortality 52 percent higher than that of those who did not inhale. "An urban/rural comparison was made between males of equivalent cigarette smoking habits and nonsmokers. It was found that the death rate for overall mortality of. urban. dwellers (persons with a history of 5 years or more.of city residence) was 12 percent higher than that for rural dwellers of comparable smoking habit$: "Respondents were classifiedl into occupational groups based on their history of occupation. No evidence was found in this study of clear-eut associations between cause of death and occupation. Further, occupation didl not appear to modify tlhe established asaociationn of cigarette smokers with death rates in excess of those of nonsmokers." SOME GENERAL CONSIDERATIONS Iky The problem of how best to measure the relationship between smok- ing and mortality has been discussed in the Surgeoni GeneraI's 1964 Report as well as iir some of the prospective stludy reports. As the amount of data. available. increases, the person-years of observations in the many population subgroups that are worthi examining increases so.that stable rates may be computed and compared. A brief discussion of three measures of comparison available and their utility seems desirable as confusion frequently arises over these measurea 1. Mortality Ratios: Obtained by dividing the death rate for a classification of smokers. by the death rate of a comparable group of nonsmokers. 2.. Differencesin. Mortality Rates.: Obtainerl by subtracting from the death rate for smokers, the death rate of' a eomparable group of nonsmokers. 3: Excess Deaths: Obtained by subtraeting, from the number of deaths occurring,in agroup of smokers the number of deaths 11

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t6 3. Exceea Deatha aa a Percentage of Totad Deatha-As with mor- tality ratios, this statistic appears to be highest in the age group 45-54 where it reaches 43 percent in one group of men and 38 percent in the other. Hammond's data by 5-year age groups show the highest rate at ages 45-49, where it is 44 percent. Reviewing both study groups it appears that for men between the ages of 35 and 60 approximately one-third of all deaths that occur are excess deaths in the sense that they would not have occurred as early as they did if cigarette smokers had the same death rates as the nonsmoking group. For women, the percentage is much lower, reaching a peak of 9 percent of all deaths in age group 45-54. It should be noted that this measure not only de- pends on the differences in death rates between the smokers and the nonsmokers, but also on the proportion of smokers in the group. Thus, even with a large difference in rates between smokers and nonsmokers, a population with very few smokers would have very few excess deaths. This measure is therefore an indicator of the public health sigruficmrce of the differences found since it measures the number of people affected and therefore the magnitude of the problem for society as a whola Once the magnitude of the excess is identified the problem becomes one of determining (1) how much of the eacess would not have oc- curred if it had not been for cigarette smoking and (2) how much would have occurred anyhow. It should be noted that much of the ex- cess has already been identified as belonging in the first category. Of the remainder, little of the excess has been clearly identified as belong- ing in the second category-that is, not caused by smoking. With most of that remainder there is uncertainty as to the category in which it. belongs. MEasunes oF Earosoxs Studies involving smoking, whether epidemiological or behavioral, have been concerned with measures of exposure to tobacco smoke. For the most part, these studies have been restricted principally to the in- dex of number of cigarettes smoked over a specified period of time, usually an "average day." The heavy reliance on numbers of cigarettes alone as a measure has produced important findings but it has possi- bly obscured others. The new reports on the prospective studies have provided a substantial amount of data to support the concept that many elements should enter into an overall measure of exposure. Such factors as age at beginning smoking, duration of smoking, and inhala-. tion have all shown some independent contributions to the overall effect, along with numbers of cigarettes. A recent report (12) has at- tempted to develop a more adequate measure of exposure in which various individual components of dosage would be combined to form composite scores. .~, ._ 14 u.+-.Fr._:. u... . ... . . _ a a..n_.Gr..- ~ _-.L < I

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CHAPTER 1 Smoking and Cardiovascular Diseases CONTENTS Page timoking and Coronary Heart Disease....................... 47 Coronary Heart Disease Mortalit'y .................... 47 Coronary Heart IDiseasel4forllidity ..................... 53 Manifestations of'Coronary Heart Disease .............. 58' Cardiovascular Response to Smoking and/or I+Iicotfiete.... 60 Coronary Blood Flow inrn Normal Subjects .......... 60 Coronary B1ood Flov in Subjects With Cbronary Heart. Disease ................................. ... ........... 6'.I. Carbon.-Monoxidie Effectl ......................... 62' Studies on In Vitro Thrombus Formation ..... ..... 64 Autopsy Studies ................................................ 6'.5~ Smoking andl Cerebrovascular Disease..................... . 66' Smoking andl Aortic Aneurysm ............................ 69' Cited References ........................................ 6'.9. Supplemental References................................. ............ 76'~ 45

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T Smoking and Overall Morbidity r THE TrmE of the Surgeon General's 1964 Report there was no A information availiable on the overall' disability associated with smoking. To incestigate the. relationship between smoking and' mor- bidity, the National Center for Health Statistics of the Public Heal!Gh Service introduced questions about cigarette smoking into iits National HeaIth. Survey,., beginning in. July 1964. This. Surveyis a continuing study conducted'since195Z. Inn carrying on th is.Su.rvey,interviewers eaahh year vi'sit 42,006W fami- lies (selected as a, probability sample of the civilian, noninstitiutional population of the United Stat'es)) and'question them about illness, dis- ability, and days absent from work because of illnessas well as the nature of tfiee illness.. In the year ending in JYme.1965, they inquired (after all other questions about headtlh had been asked) about the smok- ing habits of'persons in the family who were 17 years of age or over. The National Health Survey is concerned with three overall meas- uresof the impact of illness. 1. Days Lost From Work.-These are days absent from job or busi'- neasbecause of illness or injiury. They apply onlly to those persons who are currently employed and are therefore heavily concentrated in agegroups I7-64.. 2. Bed Dnys.-These are days when the person is sufficiently ill or disabled so as t'o spend all or most of' the day in bed,, either at home or ini a hospital. All days spent as a hospital patient are included. 3.. Days of Restvicted Activzty.-These are days when.a person cuts down, his usual activities for most of a day because of an illness or an injury. Dayslost from work because of'illnessand bed days are, of eourse, counted as days of restricted activity. This represents the most general measure of di'sabillty available in the United States today:, Table 3 summarizes the findings in a form similar to that used for summarizing, the overall mortality utilizing t.hreemeasures of. mor- bidity effect: Morbidity ratios,,difPerences in rates,,and'eaeess days of d'isability. f

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Os by 11 HIGiHLIGITTS OF CURR.ENT INFORMATION dfiffer- iJ3ficmlt tudies 3ition, ang is J Even §ymp- itug is hough ratory !h one e have alities dem 'ieredk bron, dl air ang is' IflrIDs's lchiall dYuced iveo- ~rtant fmnary thiis rm or ;e evi- IItal) intant ~ put NPhy- 1. Nlew data.confirm and to some extent strengthen the conclu- sions of the Surgeon General's 1964 Report. 2. Cigarette smoking is the most important of'the causes of chronic' non-neoplastic bronchopulimonary diseases in the United States. It greatly increases the risk of dying not only from both chronic bron. clutisbut also firom pulmonary emphysema.. 3. Cessation of smoking is followed by a reduction in mortality from chronic bronchopulmonary disease relative to the mortality of those who continue to smoke. 4. Even relatively young cigarette smokers frequently have demon- strable respiratory sy~mptoms and reduction in~ ventilat;ory function.

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4. Cessation or appreciable reduction of cigarette smoking could delay or avert a substantial portion of deaths which occur from lung cancer, a substantial portion of the earlier deaths and excess disability from chronic bronchopulmonary diseases, and a portion of the earlier deaths and excess disability of osrdiovas- + cularorigin. f: A51~'f.i:'Y't,}'-4 . NATURE OF RECENT RESEARCH FINDINGS ` ~ Since the Surgeon General's Report was published in January 1964, there has been a proliferation of additional studies and reports on smoking research. In the 12 years'preceding that report, some 3,000 articles were published reporting research; since 1964, there have been ry.t more than 2,000 additional studies. az These studies have helped to clarify the role that age plays in the rt; relationship of smoking to health; the similarities and differences in the ways in which men and women are affected by smoking; and the influences and effects of stopping smoking, particularly in the case of lung cancer where there is significant data to show that sharp reduc- tions in lung cancer deaths follow closely reductions in cigarette smoking. The studies also suggest the importance of a variety of measures of exposure; add substantial new information on the magni- tude of the morbidity problem associated with smoking; and provide more adequate data upon which to base estimates of the magnitude of the mortality problem. Historically, concern about the effects of smoking began with ob- servations of the extremely high frequency with which lung cancer patients were identified as cigarette smokeia Thesa observations took i on a fuller meaning with the first publication of the prospective studies "i' in 1954 when higher overall death rates among cigarette smokers were identified. The rates were found to exceed the difference that could be accounted for by lung cancer alone. Until that time, the possibility remained that although more cigarette smokers appeared to suffer from lung cancer, if there were no significant excess overall mortality, some other cause or causes of mortality would have had to be underrepresented among cigarette smokers. The Surgeon General's 1964 Report concluded that cigarette smokers do have higher death rates than their nonsmoking counterparts. This has changed the emphasis of the present problem away from the ques- tion tion "does cigarette smoking cause diseasel" to the more precise questionsof: . . .- ...< .. : .:. . ~. _..:..: , ~: 1. How much mortality and excess disability are associated with smoking4 } e 0 _j ;4+,»'iA ~n!r:eel r'_@;',l96 a.

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