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Reducing the Health Consequences of Smoking ! 25 YEARS OF PROGRESS a report of the Surgeon General 1989 1; DcvARTti+rNT OF +EA''~ AND NU:"AN SERVICES tinn'~h Snrv~cr ~~........... ~ .

PROP''"TY OF Wamb iC , C.., ' " ^:co 66L9 Z85t5 Reducing the ' Health Consequences of Smoking , 25 YEARS OF PROG1ESS a report of the ' Surgeon General ' 1989 ; . • U.S DEPARTMENT OF HEAITH AND HUMAN SERVICES PubNc H.Nth Swdn = ~ ~ Ornt.rs for Disw.. Conhd R : C.nt.r for ChnonOc da.... Pr.wrdlon and H..Mh Promotion ° l OMbx, on Srzwldnp and HaM "/MI , .. MwryIN1d 20a57 ppe;_ t

CHAPTER 1 HISTORICAL PERSPECTIVE, OVERVIEW, AND CONCLUSIONS ' ' Ei89 18SI5

FOREWORD Z089 i85TS Twenty-five years have elapsed since publication of the landmat!k report of the Sur- geon General's Advisory Committee on Smoking and Health. By any measure. these 25 years have witnessed dramatic changes in attitudes toward and uie-of tobacco in the United States. The health consequences of tobacco use will be with us for many years to come, but those consequences have been greatly reduced by the social revolution that has occurred during this period with regard to smoking. ( Since 1964, substantial changes have occurred in scientific knowledge of the health hazards of smoking, in the impact of smoking on mortality, in pubiic knowledge of the dangers of smoking, in the prevalence of smoking and using other "forms of tobacco, in the availability of programs to help smokers quit, and in the number of policies that en- courage nonsmoking behavior and protect nonsmokers from expqsure to environmen- tal tobacco smoke. These changes and other significant developments. as well ac the overall impact of the Nation's antismoking activities, are reviewed in;detail in the in- dividual chapters of this Report. Based on this review, five majcx`conclusions of the entire Report were reached. The first two conclusions highlight,important gains in preventing smoking and smoking-related disease in the United States. The last three conclusions emphasize sources of continuing concern and rcmaining challenges. The conclusions are: 1. The prevalence of smoking among adults decreased from 40 percent In 1965 to 29 percent In 1987. Nearly half of all living adults who ever smoked have quit. 2. Between 1964 and 119115, approximately three-quarters of a million smok- inR-reiated deaths were avoided or postponed as a resuit of decisions to quit smoking or not to start. F.ach of these avoided or postponed deaths repre- sented an averaRe Eain in life expectancy of two decades. 3. The prevalence of smoking remains higher among blacks, blue-collar workers, and less educated persons than in the overall population. The decline in smoking has been substantially slower among women than among men. 4. Smoking begins primarily during childhood and adokscence. The age of initiation has fallen over time, particularly among females. Smoking among high school seniors kveled off from 1980 through 1997 aafter pre- vious years of decline. 5. Smoking is responsible for more than one of every six deaths in the United States. Smoking remains the single most important preventable cause of death in our society.

ZZ89 18SZ5 TABLE OF CONTENTS Foreword ............................................................i Preface ...................................................:.........iii Acknowledgments ....................................................ix 1. Historical Perspective, Overview, and Conclusions ............. : ........ 1 2. Advances in Knowledge of the Health Consequences of Smoking..'. ....... 33 3. Changes in Smoking-Attributable Mortality ........................... 117 4. Trends in Public Beliefs, Attitudes, and Opinions About Smoking ........ 171 5. Changes in Smoking Behavior and Knowledge About Detertmnants, ...... 259 6. Smoking Prevention. Cessation, and Advocacy Activities ................ ~377 7. Smoking Control Policies ............................... . . r . . . . . . . 461 8. Changes in the Smoking-and-Health Environment: Behavioral and ; Health Consequences .................................. ....... ' 637 Glossary .................................................. ........ 677

the ks+ons we have karned in the United Staea, as detailed in this Report, will help other countries take the necessary steps to avoid the devastation caused by use of tobacco. C. Everett Koop, M.D., Sc.D. Surgeon General 9089 I85tS ACKNOWLEDGMENTS 'ihis Report was prepared by the Department of Health and Human Services under the general editorship of the Office on Smoking and Health, Ronald M. Davis, M.D.. Director. The Managing Editors were Susan Hawk, Ed.M.. M.S., and Thomas E. Novotny. M.D., Office on Smoking and Health. !, The scientific editors of the Report were: I Kenneth E. Warner, Ph.D. (Senior Scientific Editor), Professor, Depattlment of Public Health Policy and Administration. School of Public Health, Universlity of Michigan, Ann Arbor. Michigan Ronald M. Davis. M.D., Director. Office on Smoking and Health. Cenjer for Chronic Disease Prevention and Health Prontotion, Centers for Disease Control, Rockville, Maryland John H. Holbrook, M.D., Professor of Internal Medicine, Department of Internal Medicine, University Hospital, Sah [ske City, Utah Tfwmas E. Novotny, M.D., Medical Epidemiobgist. Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control. Rockvilk, Maryland I Judith K. Ockene. Ph.D., Associate Professor of Medicine, and Director. Division of Preventive and Behavioral Medicine, Department of Medicine. University of Mas- sachusetts Medical School, Worcester, Massachusetts Nancy A. Rigotti, M.D., Associate Director, Institute for the Study of Smoking Be- havior and Policy, John F. Kennedy School of Government. Harvard Universiry, Cambridge, Massachusetts, Instructor in Medicine, Harvard Medical School, Bos- ton, Massachusetts The jorlowing individuals prtpared dmJr ehopttrs or portions of the Rrport. Elvin E. Adams, M.D., M.P.H., Associate Dinector. Health Department, General Con- ference of Seventh-Day Adventists, Washington. D.C. Gregory N. Connolly, D.M.D., M.P.H.. Director. Office for Nonsmoking and Health. Massachusetts Depattment of Public Health, Boston. Massachusetts K. Michael Cummin&t, Ph.D., M.P.H., Ditector, Smoking Control Program, Roswell Park Memorial Institute, Buffalo, New York I viii

. ~ The Ilenorable Coerge Sesh President of the Senate Washinston, D.C. 20515 1r.. ?Q s" ( I tNt SeC.r rAa V p1 N(Al7N AIIp NUM/1N Sc e V/CC S rAY~hO~Ow.OC Mn~ ~ It is 4 pleanre to transnlt to the Conares the ~1969 .SurReon Gneral•e Repert en the health een.puenees of nakfnR, sa :andated by Section 6(a) of the Public Realtlt Cigarette S.okina AcF of 1969. iThe report was prepared by the Centers for Disease Control's Office on Smoking and Realth. Daar Mr. Treeidents r This reprt, entitled R tn *a e. 1 b Con eawencaa of emiDR; 2S 7aars sf praarau, examines the funda.eetal de.elop.ents e.er the peat quarter century in Smoking pre.alenee and in mortality cau.ed by s.okinR. It highlights important Sains in preventing ewokNnb and saakfna-related disease, reviena changes in programs and policies designed to reduee a.oking, and mph.sises aourcee of continuing concern and ressaining challenges. During the past 25 year., Smoking behavior haa changed dramatically. ltearly half of all living adults vho e.er seaked have quit. The prevalence of Smoking has declined steedily, with a particularly l.pressi.e decline among men. Smoking prevalence a.onR .en decreased from 50 percent in 196S to 32 percent in 1997. As a result, long eaaeer mortality rates among .en are now leveling off after many decades of consistent inerease. Despite this proaress, the prevalence of Smoking reusins higher awonR blacks, blue-collar vorkers, and lese-edacated persons, than in the overall population. Smoking among high school seeiora leveled off from 1961 through 1967 after previous years,of decline. In 19139 the last year for which eatimates are available, approximately 190,000 A.erieans died as the result of past and current e.okinR. This represents more than one of every six deatha in the United States. Smoking re.ains tha single .ost iportent preventable caeae of death in our socieq. To maintain our .esnta toward a wske-free soeiet>r, we .ast focus our efforts on preventing Smoking initfation and encouraging Smoking cessation a~on{ bl{h-risk populations. Inereaaed public fnfor.atfon activities, Smoking prevention and cessation proaraws, and policies that encourage nonsmoking behavior should be pursued. Unless we meet thtn challende successfully, sookins-related mortality vill remain high well into the 21st Century. Sincerely, 0-**7'-- -„~. ,,,., Q e- Otia R. seven, M.D. Secretary 1089 Z 8 5 i S snclosere

I I CONTENTS bt89 tBStS I HistoricalPerspective ................................................ 5 Highlights of Conclusions and Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Major Conclusions ................................................ 11 Key New Findings ................................................. 11 Overview ..............................................• • ......13 `r Coverage of the Report .................................... .......13 1990 Health Objectives for the Nation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Limitations of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Development of the Report .......................................... 19 Chapter Conclusions ........................................ .......20 Chapter 2: Advances in Knowledge of the Health Consequences of Sr{ioking . 20 Part 1. Health Consequences . . . . . . . . . . . . . . . . . . . . . . . . . .~.I . . . . . . 20 Part 11. The Physicochemical Nature of Tobacc.~o . . . . . . . . .•'r. . . . . . . 21 Chapter 3: Changes in Smoking-Attributable Mortality . . . . . . . . . . . . . . . . . 21 Chapter 4: Trends in Public Beliefs. Attitudes. and Opinions About Sinnoking . 22 Chapter 5: Changes in Smoking Behavior and Knowledge About ! Determinants .......................................... ....23 Part 1. Changes in Smoking Behavior . . . . . . . . . . . . . . . . . . . .:. . : . . . . 23 Part H. Changes in Knowledge About the Determinants of Smoking Behavior ..........................................24 Chapter 6: Smoking Preventlott, Cessation, and Advocacy Activities ........ 25 Part 1. Smoking Prevention Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Part It. Smoking Education and Cessation Activities . . . . . . . . . . . . . . . 25 Part Ili. Anti.cmoking Advocacy and Lobbying . . . . . . . . . . . . . . . . . . . . . 26 Chapter 7: Smoking Control Policies . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . 26 Part I. Policies Pertaining to Information and Education . . . . . . . . . . . . . 26 Part II.EconomicIncentives ................................... 27 Part til. Direct Restrictions on Smoking . . . . . . . . . . . . . . . . : . . . . . . . . . 28 Chapter 8: Changes in the Smoking-and-Health Environment: Behavioral and Health Consequences ............................................. 28 References ......................................................... 30 I

1 5t89 t8SZ5 Historical Perspective Each of the last five Surgeons General of the U.S. Public Health Service (aHS) has Identified cigarette smoking as one of this Nation's tnost significant sourres of death and disease. Today, more than one of every six American deaths is the result of cigarette smoking. Smoking is responsible for an estimated 30 percent of all cancer deaths, in- cluding 87 percent of lung cancer, the leading cause of cancer mortality; 21 percent of deaths from coronary heart disease;18 percent of stroke deaths; and 82 percent of deaths fnxn chronic obstructive pulmonary disease. Other forms of tobacco u3e. including pipe and cigar smoking and use of smokeless tobacco, are also associated with sig- nificantly elevated risks of disease and death (US DHEW 1979a; US DHHS 1986b). Although the health hazards of tobacco use have been suspected for almost 400 years, the first reported clinical impressions of a relationship between tobacco and disease date from the 18th century, when tobacco use was associated with lip!cancer (US DHEW 1979a)and nasal cancer (US DHHS 1986b). However, true scidntifiic under- standing of the health effects of tobacco has been achieved only in the prrsent century. Broders (1920) published an article in the lownal of the Anterican Medical Associa- tion linking tobacco use to lip cancer, and 8 years later. Lombard and Doering (1928) published an article in the New England lournal of Medicine noting thaO heavy smok- ing was more common among cancer patients than among control groups. Later. Pearl (1938) observed in the journal Science that heavy smokers had a shorter li fe ~cpectan- cy than nonsmokers. During the 19,70s, the Nation'a Increasing rate of lung cancer and other diseases prompted the initiation of epidemiologic and laboratory studies of the relationship be- tween tobacco use and disease. In the late 1940s and early 1950s, a number of retrospec- tive epidemiologic studies, published by Wynder and Graham (1950) and by other in- vestigators, provided scientific evidence strongly linking smoking to lung cancer. This association was soon thereafter supported by the emerging early findings of major prospective (cohort) mortality studies, including the work of Doll and Hill (1954,1956) in Great Britain and Hammond and Horn (1958a, 1958b) in the United States. The stnength and consistency of these results, combined with evidence from laboratory and autopsy studies, led a national scientific study group to conclude in 1957 that the relationship between smoking and lung cancer was causal (Study Group on Smoking and Health 1957). On July 12 of that year, U.S. Surgeon General Leroy Burney issued a statement declaring that "The Public Health Service feels the weight of the evidence is increas- ingly pointing in one direction; that excessive smoking is one of the causative factors in lung cancer" (US PHS 1964). Two years later, in 1959, Surgeon General Burney said that "The weight of evidence at present implicates smoking as the principal factor in the increased incidence of lung cancer" (Burney 1959). Increases in chronic diseases in other parts of the world led health authorities in other countries to examine the relationship between tobacco and diaease, particularly in Europe and Scandinavia. ln 1957, the British Medical Research Council reported that a major part of the incnease in lung cancer was attributable to smoking (British Medi- cal Research Council 1957). Later, the Royal College of Physicians (1962) issued a S a

Joanna Ebling, Word Processing Specialist, The Circle. Inc., McLean. Virginia David Fry, Editor. The Circle. Inc., Mckan, Virginia Lynn Funkhausrr. Word Processing Specialist. The Circle. ine., McLean. Virginia Amy Garson, Student Intern, Office on Smoking and Health, Rockville. Maryland Gary A. Giovino, Ph.D.. Epidemiologist, Office on Smoking and Health, Rockville, Maryland Ametta G. Glover, Secretary, Office on Smoking and Health. Rockville, Maryland Victoria M. Grier. Conference Coordinator. The Circle. Inc., McLean, Virginia Andree C. Harric, Program Analyst. Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. Atlanta, Georgia Evridiki Hatziandreu. M.D., Dr.P.H., Epidemic Intelligence Service Officer, Office on Smoking and Health, Rockvilk, Maryland Patricia E. Healy. Technical Information Spacialist, Office on Smoking and Health, Rockville, Maryland Timothy K. Hensley, Technical Publications Writer, Office on Smoking and Health, Rockville, Maryland Robert S. Hutchings, Associate Dineetor for Infonnation and Program Developnent, Office on Smoking and Health, Rockvilk, Maryland Karen Jacob. Senior Editor. The Circle. Inc., McLean, Virginia Beth Jacobsen. Student Intern, Office on Smoking and Health. Rockville, Maryland Sheila M. Jones. Word Processing Specialist. The Circle. Inc., McLean, Virginia Kathleen M. Keever, Secretary, Department of Public Health Policy and Administra- tion. School of Public Health. University of Michigan. Ann Arbor. Michigan Rick Keir. Senior Editor, Tfie Circle. lnc., McLean, Virginia Jennifer L. Kirxht, M.P.H., Statistics Consultant, Department of Public Health Policy and Administration, School of Public Health, University of Michigan, Ann Arbor, Michigan Laura Y. Martin, Program Andyst, Office of Program Planning and Evaluation, Centets for Disea.ce Control. Atlanta, Georgia Daniel F. McLaughlin, Editor, The Circle. Ine., McLeen, Virginia Sherry L M ills, M.D., M.P.H., Epidemic Intelligence Service Of'f+cer, Office on Smok- ing and Health, Rockville, Maryland Nancy A. Miltenberger, M.A., Senior Editor, The Circle. Inc., McLean, Virginia Elizalxth Mugge. Special Assistant, Office of the Deputy Director, Division of Cancer Prrvention and Controi, National Cancer Institute, Bethesda, Maryland Millie R. Naquin, M.Ed., Research Assistant, Office on Smoking and Heahh, Rock- ville, Maryland Regina Nwankwo, Editor, The Circle. Inc., McLean, Virginia Ruth C. Palmer, Secretary, Office on Smoking and Health. Rockville. Maryland Lida Peterson. Computer Systems Manager. The Circle. lnc., McLean, Virginia Renate Phillips. Desktop Publishing/iGraphic Artist, The Circle. lnc., McLsan, Virginia Margaret E. Pickerel, Public Information and Publications Specialist, Office on Smok- ing and Health, Rockville, Maryland Tamara Shipp. Publications Assistant, The Circle. lnc., McLean, Virginia Edwin Silverberg, Supervisor, Statistical Information Service, American Cancer Society Linda R. Spiegelman. Administrative Officer, Office on Smoking and Health, Rock- ville. Maryland Traion Stallings, Word Processing Specialist, The Circle, lnc., McLean, Virginia Daniel R. Tisch, Senior Project Manager. The Circle, Inc., Mci.ean, Virginia Pamela Wilson. Editor, The Circle, Inc., McLean, Virginia Louise G. Wiseman, Technical Information Specialist, Office on Smoking an4Health, Rockville. Maryland I 1189 t85t5 xix