Tobacco Documents Online

I nQ aeatrMw er KAtrw re Mw.w rt.v.ets .rr...w. u. .w, . . Suggested Citation U.S. Department of Health and Human Services. Reducing the Health Consequen- crs of Smoking: 25 Years of Progress. A Report of the Surgeon General. U.S. Depart- ment of Health and Human Services. Public Health Service. Centers for Disease Con- trol. Center for Chronic Disease Prevention and Health Promotion. Office on Smoking and Health. DHHS Publication No. (CDC) 89-l441 I, Prepublication versicxl, January 11, 19R9. This is a prepublicaticxl version of the Report. The final version, with index, will be available later in 1999. tlr a..erable ,li. rrtght spo.kar ee the Ne.ao of Rqr.N.t.t1Na reohtagtea, D.C. 20313 ll.ar Mr. apoal.rl It ta 4p1...are to tr....tt to the Catttmaa H. /!N t.rge.a O.aar.1'a aeprt es the Iraltb eawt.eaeea of ..e4twg; r rnr.t.d by lLettaa a(.) ei the f.blte a.alth Clpr+tte 1.okint " o!, Hbf. Tho repert wprpar./ by the CGat.ra for at.e..e Coetrol'a Orllee as a.nktett .d sa.lth. 81S report. .atttl.d W.ala~ tlw lt.alth Ce.wt..ie.. e! artlni: 23 T.aro et h~a[reoa, es..t.oo th. . a..at• develoyaaat. e.er the wt q+arter eont.rl is .askttg rro.aleeee ..d ie .oit.ltt7 ewwA by o.altag. It higbligAto taprtant gataa to t.roreattej ..ntlng .d avokiag-r.1.taN dlaea.e, r..i..a eha.pe ia rrosr.r and plietos h.tpM to rM+ea ..ettag, .at aaph.elt.a .e.reee of eenttaalag re.pra wd rerl.tag eballeagea. ' tl.rtaa the pat 23 y.arn, .rklaa bati.Her lw eha,qd 4ra.Kiea117. taarl7 half e[ .il lt.t% N.lt. .hs e..r e.n4.d ba.* t.it. The pro..ls.ee of ...klag hr Mel1w.N atoadi:y, rtth a prtte.larly l.proaotw doelir a.a.g ..a. fstf.ag pr...lesee ..e" rn deere.ad lre. 30 pareoat ta 1li3 to 32 pareowt ta 1967. An a rea.lt, l..a caae.r .ort.ltty rat.a a.att! .aa .ta ss. le..ltag off after,rq deeMos of eea.taNat laer./ae. Ooqite tbie hragroaa, the pro.alonee of .aeltag mair higher ..aag bl.el., bl.a-eellar .orbra, and leae-edue.t.d Parae.., tlw ta tho ererall pplatlew. li.ekin{ .aoet high aeheel aaaton l.wld .[[ [roe ltai through 1l117 atter pro.leeo 7.ara of bcll.a. It 1905. tAe lNt Ta.r for sMeA ..tl.at.s ar. ..atlabl.. MPr.:irt.ly 730,000 Arrte.aa dl.l r th@ r...lt of past aad e.rn.t aettag. ZMa rahreaaata sre tAan awa of o..ry aln d.aths ta the OattM ft.toa. g.ettae ra..lr the ataale .n.t t.portant pnventdle e.rN e! Mattt t.o o.r a.elety. ?o rtwqts .ar a.aatan twad a asba-hro aootetlr, .a awt [ee.m our et[orts ea l.ra.eatittg amkta{ lattiatlen ..d oecooragtag a.ekia` ee...ttea aaaag Mgh-rtak prel.tten.. Ieeroa.ed public tntor..tlon .ctt.ittea, .uetttag pr..eattew .ad e.a..tlen presra.., and pltel.e that eneo.r.q wenasking bahavler should bN penwA. Unlo.s we aeet thta ehallenp .aee..oL.i17, .aoktft-r.l.ted asrt.llt>r .til re.aln htth well tate the 21st Ceat.ry. titae.rely, 0089 18StS 4.~ Otta l. Dow., M.D. Soeretary saeloa.r.

0£89 t85tS CONTENTS Introduction ........................................................ 37 Partl: Health Consequences .......................................... 38 Smoking and Overall Mortality ...................................... 38 Lung Cancer ..................................................... 43 Introduction ................................................. 43 Dose-Response Relationships ............................... ! ~ .. 43 Women and Lung Cancer ...................................... 46 Type of Lung Cancer and Smoking ............................... 50 Pipe and Cigar Smoking ....................................... 50 Determinants of Susceptibility .................................. 50 Familial Factors ....................................... •... 52 Other Host Factors .................................... 52 Occupational Exposures ............................... ~. . . : 52 Ambient Air Pollution ...................................... 53 Indoor Air Pollution .................................... ... 53 Diet .................................................... 54 Smoking Cessation ........................................... 55 Laryngeal, Oral, and Esophageal Cancer ....i. 56 Bladder and Kidney Cancer .....................................'...'. 56 Pancreatic Cancer ................................................. 56 Stomach Cancer ...............................................'....57 Cervical Cancer ................................................... 57 Endometrial Cancer ............................................... 58 Coronary Heart Disease ............................................ 58 Epidemiology .......................................... .. 58 Coronary Heart Disease Risk Factors ............................ 59 Pathophysiological Mechanisms ................................ 60 Clinical Correlations .......................................... 61 Smoking Cessation ........................................... 61 Cerebrovaccular Disease (Stroke) ..................................... 61 Atherosclerotic Peripheral Vascular Disease ............................ 64 Atherosclerotic Aortic Aneurysm ..................................... 65 Chronic Obstructive Pulmonary Disease ............................... 66 Pathogenesis ................................................ 67 Pathophysiology ............................................. 67 Natural History of COPD and the Role of Ciganme Smoking ......... 68 Pregnancy andlnfant Health ......................................... 71 Infant Birthweight ........................................... 72 Fetal and Perinatal Mortality ................................... 73 Congenital Malformations ................................. . . . 73 Fertility .................................................... 75 Long-Tctm Effects on the Child .................. . . . . .......... 75 Peptic Ulcer ...................................................... 76 35 I

U.S. DF.PARTMENT OF HEALTH. EDUCATION. AND WELFARE. San Diego Smoking Rr.crarrhPrnjec•t. FiwYrorStatus. U.S.DepartmentofHealthEducation,andWelfarc,Cen- tcr for Disease Control. DHEW Project No. 200-7S-0S 16:1-7, 1976. U.S. DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE. The Health Canss- qnrnre.c n/SmnkinR,1977-197R. U.S. Department of Health, EAucation, and Welfare. Public Health Service. Office of the Asaistant Secretary for Health. Office on Smoking and Health. DI IF.W Publication No. (PHS) 79-Stttl6S, 197R. U. S. 1)EI'ARTMENT OF HEALTH. EDUCATION. AND WELFARE. Smnking and Health. A Report of the Sur.etnn General. U.S. Department of Health. F.ducaticxt, and Welfare. Public Health Service, Office of the Assistant Secretary for Heallh. Office on Smoking and Health. fri1t;W Publication No. (PHS) 79-5(11)66, 1()7qa. U.S DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE. Healthy People. The .CurRenn Grnrrars Report nn Hrolth PrnmMinn and ni.amsr Preventinn. U.S. Department of Ikalth. F.ducatinn, and Welfare, Public Health Service. Office of the Ascistant Secretary fox Health. DIIFW Publication No. 79-55(171, 1Q79h. U.S. PUBLIC HEALTH SERVICE. SmnkinR and Health. Rennrt of the Advisory Committee to the.SurRron General ejthe Public HrahhStrvirt. U.S. Department of Health. EAocatiort, and Welfare, Public Health Service, Center ftx Disewe Control. PHS Publication No. 1103, 1964. U.S. PUBLIC HEALTH SERVICE. The Health Consequtncts nJSmnking. A Public Strvict Review: 1967. U.S. Depariment of Halth. Educatan, and Welfare. Public Health Service. Health Services and Mental Health Adminictration. PHS Publication No. 1696. revised 196Ra. U.S. PUBLIC HEALTH SERVICE. Tht Health Cnnstqrthtts of Smnking. 19tfR Srqqrlenrtnt to the 1967 Public Health Service Rrview. U.S. Depatrtment of Health. Education, and Wel- fare. Public Health Service, Health Servica and Mental Adminixtration. DHEW Publication No. 1696, 196Rb. U.S. PUBLIC HEALTH SERVICE. The Health Cnn.aqrtnees ojSmokinR. 1969 Supplement to thr 1967 Public Health Service Review. U.S. Department of Health. Education, and Wel- fare. Public Health Service. DHEW Publication No. 1969-2 (Supplement), 1969. WYNf)ER, E.L., GRAHAM, E.A. Tobacco smokin6 as a Poc.cible etioloRic factor in bronchiogenic carcitwxna: A study of 694 proved craes. Journal njtht American Medical Association 14.1:i29¢i96, May 27, 19.50, 6Z89 Z8SiS CHAPTER 2 r ADVANCES IN KNOWLEDGE OF THE HEALTH CONSEQUENCES OF SMOKINq :~:~

;7! lack E. Henningfield. Ph.D.. Chief, Biology of Dependence and Abuse Potential As- sessment Labnratory, Addiction Research Center, National Institute on Drug Abuse, Baltimore, Maryland Carol J. HoFue, Ph.D.. Director. Division of Reproductive Health. Center for Chronic Disease Prevention and Health Pronation, Centers for Disease Control, Atlanta, Georgia Elvin Hityer, Associate Director for Policy Coordination, Centers for Disease Control, Atlanta. Georgia Richard lessor, Ph.D.. Professor of Psychokogy. Director of the Institute of Behavioral Science. University of Colorado at Boulder. Boulder. Colorado Lloyd D.lohnston, Ph.D.. Program Director. Institute for Social Research, University of Michigan. Ann Arbor, Michigan John T. Kalherer, Jr., Ph.D.. Deputy Director. Division of Disease Prevention, Office of Disease Prevention, Office of the Director. National Institutes of Health, Bethes- da, Maryland John H. Kelso, Acting Administrator, Health Resources and Services Administration, Rockville, Maryland Larry Kessler, Sc.D., Surveillance and Operations Research Branch, National Cancer Institute. Bethesda, Maryland A. Joan Klebba, M.A., Statistician, Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control, Hyattsville. Maryland Lloyd J. Kolbe, Ph.D.. Acting Director. Division of Adolescent and School Health. Cen- ter for Chronic Disease Prevention and Health Prorration, Centers for Disease Con- trol. Atlanta. Georgia Jeffrey P. Koplan, M.D.. M.P.H., Dinector, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia Lynn T. Kozlowski, Ph.D.. Head. Behavioral Research on Tobacco Use. Addiction Re- search Foundation, Toronto, Ontario, Canada Marshall W. Krcuter, Ph.D., Din.ctor, Division of Chronic Disease Control and Com- munity Intervention, Center for Chronic Disease Prevention and Health Promotion, Centers for Diseaie Ctfnhiol, Atlatna, Georgia Narry A. Lando, Ph.D., Associate Profe.ssor, Division of Epidemiology. School of Public Health, University of Minne.sota, Minneapolis, Minnesota Charles A. LeMaistre, M.D., President, University of Texas M.D. Anderson Cancer Center, Houston, Texas Claude Lenfant, M.D., Director. National Heatt, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Eugene M. Lewit, Ph.D., Associate Profes.sor, Departments of Medicine and Preven- tive Medicine and Community Health, Office of Primary Health Care Education, UMDNJ-New Jersey Medical School, Newark, New Jersey Bryan R. Luce, M.B.A.. Ph.D., Battelle Human Affairs Research Center, Washington, D.C. Dolores M. Malvih, Dr.P.H., Dental Disease Prevention Activity, Center for Preven- tion Services, Centers for Disease Control, Atlanla, Georgia AlfnedC. Marcus, Ph.D., Associate Director, Division of Cancer Control,lexrI sson Com- prtihensive Cancer Center, UniversitK of California, Los Angele's, Los Angeles, California ' James S. Marks, M.D., M.P.H.. Deputy Director for Public Health Practice, Center for Chronic Disease Prevention and Health Pronation, Centers for Disease Control. At- lanta, Georgia James O. Mason, M.D., Dr.P.H., Director. Centers for Disease Control, Atlanta, Geor- gia ' Robin 1. Mermelstein, Ph.D., Assistant Professor, Prevention Re.search Center, School of Public Health, University of Illinois at Chicago. Chicago, ltlinois Dannie C. Middleton, M.D., Medical Officer, Document Development Branch. Division of Standards Development and Technology Transfer, National Institute for Occupational Safety and Health. Centers for Disease Control, Atlanta. Georgia Gregory J. Morou:o, Ph.D., M.P.H., Coordinator, National Heart. L{ung, and Blood Institute's Smoking Education Program, National Institutes of Htalth, Bethesda, Maryland Joseph P. Mulholland, Ph.D., Bureau of Ecorwmics, Federal Trade Commission, Washington, D.C. Hillary Murt, M.P.H., Research Associate, Departrrtent of Health SerYices Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan Herbert W. Nickens, M.D.. M.A., Director, Office of Minority Health. Public Health Service, Washington, D.C. Richard W. Nietneier, Ph.D., Acting Ditector, Division of Standards I?eveloPmertt and Technology Transfer, Nationd Institute for Occupational Safety and Health. Centers for Disease Control, Atlanta, Georgia Stuart L. Nightingale, M.D.. Associate Commissioner for Health Affairs, Food and Drug Administration, Rockville, Maryland Ira S. Ockene, M.D., Professor of Medicine, Director. Preventive Cardiology. Division of Cardiovascular Medicine, University of Massachusetts Medical School, Wor- cester, Massachusetts Horace O.Ogdelt, Consultattt, Oaithersbur6, Maryland Patrick M.O'Malky Ph.D.,Associate Research Scientist, Institute forSocial Research. University of Michigan. Ann Arbor. Michigan Mario A. Orlandi, Ph.D.. M.P.H., Chief. Division of Health Promotion Research. American Health Foundation, New York, New York Carole Tracy Orleans. Ph.D., Senior Investigator. Behavioral Medicine and Director of Smoking Cessation Services, Fox Chase Cancer Center, Philadelphia, Pennsylvania Gerry Oster, Ph.D.. Vice President, Policy Analysis, Inc., Brookline, Massachusetts Clifford H. Patrick, Ph.D.. Senior Public Health Advisor. Office of Minority Health, Washington. D.C. Cheryl L. Perry, Ph.D.. Associate Profesaor, Division of EPidemioingy. School of Public Health, University of Minnesota. Minneapolis. Minnesota Michael Pertschuck, J.D., Co-director, Advocacy Institute, WashingRkxt, D.C. I 6089 IBSiS xv Xiv

Ronald M. Davis, M.D.. Director. Office on Smoking and Health. Center for Chronic Disease Prevention and Health Promcxion, Centers for Disease Control. Rockville, Maryland Joseph R. DiFram.a, M.D.. Director of Research, Fitchburg Family Practice Residen- cy Program, University of Massachusetts Medical Center, Fitchburg, Massachusetts Michael P. Eriksen, Sc.D.. Director. Behavioral Research Program, Department of Can- cer Prevention and Control, The University of Texas M.D. Anderson Cancer Center, Houston, Texas David P. Fan, Ph.D.. Professor of Genetics and Cell Biology. University of Minnesota, St. Paul. Minnesota Michael C. Fiote, M.D.. M.P.H.. Assistant Professor, Department of Medicine. Center for Health Sciences, University of Wisconsin. Madison, Wisconsin Edwin B. Fisher, Jr., Ph.D.. Associate Professor of Psychology, Director. Center for Health Behavior Researrh, Washington Univenity, St. Louis, Missouri Jeffrey E. Harris, M.D., Ph.D., Visiting Associate Professor, Department of Biostatis- tics, Harvard School of Public Health, Boston, Mac.sachusetts; Clinical Associate, Medical Services. Massachusetts General Hospital. Boston, Mas.sachu.setts; As- sociate Professor of Economics, Massachusetts Institute of Technology. Cambridge, Massachusetts Jan L Hitchcock, Ph.D., Associate Director. Institute for the Study of Smoking Be- havior and Policy, John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts Thomas A. Hodgson. Ph.D.. Chief Economist, Office of Analysis and EPidemiology, National Center for Health Statistics, Hyattsville, Maryland Dietrich Hoffmann, Ph.D., Associate Director. Naylor Dana Institute for Disease Prevention, Americatt Health Foundation, Valhalla, New York Ilse Hoffmann, Research Cootdinator, Naylor Dana Institute for Disease Prevention, American Health Foundation, Valhalla, New York Juliette S. Kendrick, M.D., Deputy Chief, Ptegnancy Epidemiology Branch, Division of Reproductive Health, Center for Chronic Disease Prevention and Health Ptvnw- tion, Centers for Disease Control, Atlanta, Georgia Lewis H. Kuller, M.D., Dr.P.H., Professor and C?tairperson. Departntent of Epidetniol- ogy, Graduate School of Public Health, University of Pitt.sMtrgh, Pittsburgh, Pennsyl- vania ~ Eugene M. Lewit, Ph.D.. Associate Professor, Departments of Medicine and Preven- tive Medicine and Community Health, Office of Primary Health Care Education, UMDNJ-New Jersey Medical School, Newark, New Jersey Edward Lichtenstein, Ph.D.. Research Scientist, Oregon Research Institute; Professor of Psychology. University of Oregon, Eugene, Oregon Thomas E. Novotny, M.D.. Medical Epidemioiogist, Office on Smoking and Heahh. Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Rockville, Maryland Judith K. Ockcne. Ph.D., Associate Professor of Medicine, and Director. Division of Preventive and Behavioral Medicine, Del+artment of Medicine. University of Mas- carhucetts Medical School, Worcecter, Massachusetts Chris Leo Pashos, M.P.P., Project Coordinator, Institute for the Study'of Smoking Be- havior and Policy, John F. Kennedy School of Government, Harvard University, Cambridge. Massachusetts Richard Peto, M.A., M.Sc., ICRF Cancer Studies Unit, Radcliffe Infirmary. Oxford, England John P. Pierce. M.Sc.. Ph.D., Chief, Epidemiology Branch, Office on Smoking and Health. Center for Chronic Disease Prevention and Health Promoticm, Centers for Disease Control. Rockville, Maryland John M. Pinney, Executive Director. Institnte for the Study of Smoking Behavior and Policy, John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts Edward T. Popper, M.B.A., D.B.A., Associate Professor of Marketing. Bryant College, Smithfield. Rhode lsland Patrick L. Remington, M.D., M.P.H.. Medical Epidemiologist. Buresu of.Community Health and Pteventiott, Wisconsin Division of Health, Madison, N~isconsin Nancy A. Rigotti, M.D., Associate Director. Institute for the Study' of Smoking Be- havior and Policy. John F. Kennedy School of Govemment, Harvard University, Cambridge, Massachusetts, and Instructor in Medicine, Harvard Il4edical School, Boston, Massachusetts Jonathan M. Samet, M.D.. Professor of Medicine, Department of Medicink, Chief, Pul- monary Division, University of New Mexico. Albuquerque. New lvlexico Russell C. Sciatdra, M.A., Associate Director. Smoking Control Program, Roswell Park Memorial institute, Buffalo, New York Carol Anne Soltanek, M.D.. Resident, Southwestern Michigan Anea Health Education Center. Kalamazoo. Michigan Michael A. Stoto, Ph.D., Senior Staff OPficer, Institute of Medicine. National Academy of Scienors, Washington. D.C. I Owen T,1ltornbetry, Ph.D., Director. Division of Health Interview Statistics, Nation- al Center for Health Statistics, Centers for Disease Control, Hyattsville. Maryland Kenneth E. Wamer, Ph.D., Professor, Department of Public Health Policy and Ad- ministration. School of Public Health, University of Michigan, Ann Arbor. Michigan The editors aCbrotvleQRe with gratitude the felfowinR distinRuishtd scienti.ctc, physicians, and othtrs who tent their sapport in the development nf this Report hv conr- dinatinR manuscript preparation, contributing critical rrviPNCC. or assisting in other ways. Elvin E. Adams, M.D., M.P.H.. Associate Director. Health Department. General Con- ference of Seventh-Day Adventist.s, Washington. D.C. Charles Althafer, M.P.H.. Assistant Director for Health Promotion and Risk Aplraical, office of Program Planning and Evaluation, National Institute for Occupational Safety tutd Health, Centers for Disease Control, Atlanta, Georgia ; Lynn M. Artz, M.D., M.P.H., Senior Policy Advisor, Oflice of Diseate Prevention -and Health Pnomotion. Office of the Assistant Secretary for Health, Washington. D.C.

~ ~ tobacco use is one of 21 priority areas in which objectives are being formulated. PHS s D » intends to publish the objectives in 1990 W S ~ a E 06 . Y 6 S L 0 ~ O » o ~•~ ~ V ...yyy A C ~ C ~ Limitations of CoveraRe espite the broad scope of this Report, certain limitations have had to he placed on . ~ ~ E ~ Q qY » V,,~~ u r m ,J Y.~ m C N ~ ";;aA °og ` 0 6 E coverage. Two in particular are worthy of mention here: . (1) The Report focuses primarily, but not exclusively, on cigarette smpking, reflect- ing its dominance among forms of tobacco use, in terms of both prevalence and disease impact. This focus also reflects the desire to represent the principal interest•of the 1964 Advisory Committee in this 25th anniversary Report. Pipe and cigar smoking are much less prevalent than cigarette smoking but also carry significant health risks (US DHEW 1979a). Growing use of smokeless tobacco products (snuff and chevying tobacco), primarily by adolescent males, has focused national attention on there vaknce and health consequences of using these tobacco products (Connolly et al. 19R6).' This sub- ject was recently reviewed thoroughly by an advisory committee to the Shrgeon General (US DHHS 19R6b) and in a National Cancer Institute monograph (Boyd and Darbey, in press). i ' (2) The Report concentrates on smoking in the United States. Both vdithin the United States and around the world, tht:re is growing concern about the spread of smoking, particularly in the world's poorer countries. While per capita cigarette eonsumption is stable or falling in most developed nations, it is rising in Third World countries. Rates of smoking-related chronic diseases are also increasing rapidly, to the point that tobac- co is expected to soon become the leading cause of premature, preventable mortality in the Third World, as it is at present in the developed world (Aoki, Hisamichi, Tominaga 1988). Concentration of this Repott on smoking in the United States is no reflection on the relative importance of the international situation. Rather, it results fnom the principal objective of reviewing where this Nation has come in its efforts to control smoking-re- lated disease since the 1964 report of the Surgeon General's Advisory Committee. The Public Health Service hopes that this review; like its predecessors, will prove to be of value to scientists, health professionals, and public health officials in countries throughout the world. Development of the Report This Report was developed by the Office on Smoking and Health (OSH). Center for Chronic Disease Prevention and Health Ptorrwtion. Centers for Disease Centrol, Public Health Service of the U.S. Department of Health and Human Services, as. part of the Department's responsibility, under Public Law 91-222, to report new and current in- formation on smoking and heahh to the U.S. Congress. The scientific content of this Report was produced through the effortt of more than ILV scientists in the fields of inedicine, the biological and social sciencec, public health, and policy analysis. Manuscripts for the Report, constituting drafts of chapters or sec- tions of chapters, were prepared by 33 scientists sclected for their expertise in the tn

, Donald A. Berreth, Director, Office of Public Affairs, Centers for Disease Control, At- lanta. Georgia Gayle M. Boyd, Ph.D., Program Director, Srnoking, Tobacco and Cancer Program, Division of Cancer Prevention and Control, National Cancer Institute, Bethesda, Maryland Allan Brandt, Ph.D., Department of Social Medicine and Health Policy, Harvard Medi- cal School. Boston, Massachusetts Lester Brcslow, M.D., M.P.H.. Professor, School of Public Health, and Director. Health Services Research, Jonsson Comprehensive Cancer. Center, University of California, Los Angeles. Los Angeles, California Clarice Brown, M.S., Data Analyst, Office of Prevention. Education, and Control, Na- tional Heart, Lung, and Blood Institute, Bethesda, Maryland David P. Brown, M.D., Deputy Director. Division of Surveillance. Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health. Centers for Disease Control, Atlanta, Georgia Martin Brown, Ph.D., Surveillance and Operations Research Branch, Division of Can- cer Prevention and Control, National Cancer Institute, Bethesda, Maryland David M. Burns, M.D., Associate Profes.sor of Medicine. Division of Pulmonary and Critical Care Medicine, University of California. San Diego Medical Center, San Diego, California Dee Burton, Ph.D.. Assistant Professor, Prevention Research Center, School of Public Health, University of Illinois at Chicago. Chicago. Illinois Frank l. Chaloupka, Ph.D., Assistant Professor, Department of Economics, Colkge of Business Administration, University of Illinois at Chicago, Chicago, Illinois Paul D. Cleary, Ph.D., Department of Health Care Policy and The Division on Aging, Harvard Medical School, Boston, Massachusetts Alexander Cohen. Ph.D.. Deputy Director, Division of Biomedical and Behavioral Science. National Institute for Occupational Safety and Health. Centers for Disease Control, Atlanta, Georgia Joel B. Cohen, Ph.D., Distinguished Service Professor and Director. Center for Con- sumer Research, University of Florida, Gainesvilk, Florida Michael J. Cowell, F.S.A., Vice President and Corporate Actuary, UNUM Life In- sdrance Company. Portland, Maine Joseph W. Cullen, Ph.D., Deputy Director. Diviaion of Cancer Prevention and Control. National Cancer Institute, Coordinator for the National Cancer Institute's Smoking. Tohacco and Cancer Program. Bethesda, Maryland Sir Richard IMll, Emeritus Professorof Medicine, University of Oxford. Acting Dinec- tor, Imperial Cancer Research Fund, Cancer Epidemiology and Clinical Trials Unit, Oxford, England J. David Erickson, D.D.S., Ph.D.. Chief, Birth Defects and Genetic Diseases Branch, Division of Birth Defects and Developmental Disabilities, Center for Environmental Ilealth and Injury Control, Centers for Disease Control, Atlanta, Georgia Michael P. Eriksen, Sc.D., Director. Behavioral Research Program, Department of Can- cer Prevention and Control. University of Texas M.D. Anderson Cancer Center, I louctnn, Tcxas , Virginia L. Emster, Ph.D., Professor of Epidemiology. Department of Epidemiology and international Health, School of Medicine. University of California. San Francis- co, California Roberta G. Ferrence, Ph.D., Ptevetttion Studies Department. Addiction Research Foun- dation, Toronto, Ontario, Canada Jonathan E. Fielding, M.D., M.P.H., Professorof Public Health and Pediatrics. Univer- sity of California at Los Angeles, Los Angeles, California. Vice President and Health Director. Johnson and Johnson Health Management, Inc.. Santa Monica, California John R. Finnegan, Jr., Ph.D., Assistant Professor, School of Public He~lth, University of Minnesota. Minneapolis. Minnesota Martin Fishbein, Ph.D., Professor of Psychology and Research Professor, Institute of Communications Research, University of Illinois, Champaign-Urbana, Illinois Brian R. Flay, D.Phil., Associate Professor and Director. Prevention Research Center. School of Public Health, University of Illinois at Chicago. Chicago,;lllinois William H. Foege. M.D., M.P.H., Executive Director, The Carter :Center, Emory University. Atlanta. Georgia Peter L. Frommer, M.D., Deputy Director, Natiotal Heart, Lung, and Blood institute, National Institutes of Health, Bethesda, Maryland Lawrence Garfinkel. M.A., Vice President for Epidemiology and St~atistics, Director, Cancer Prevention. Arnerican Cancer Society, New York, New York Donald W. Garner,l.D., Professor of Law, Southern Illinois University Sc$tool of Law, Carbondale, Illinois i I Russell E. Glasgow, Ph.D., Research Scientist, Oregon Research Institute. Eugene, Oregon Thomas J. Glynn, Ph.D.. Program Dinctor for Smoking Research, Smoking, Tobacco, and Cancer Program, National Cancer Institute, Bethesda. Maryland Frederick K. Goodwin, M.D., Administrator, Alcohol, Drug Abuse, and Mental Heahh Administntion, Rockville, Maryland , Nancy P. Gordoe, Sc.D.. Behavioral ScieMist, Division of Research. Northern Califor- nia Kaiser Permanente Medical Care Program Leonard Gnxn, Ph.D.. Professor of Psychology, Department of Psychology, Washington Univetsity, St Louis, Missouri Ellen R. Gritz, Ph.D., Director. Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of Califomia. Los Angeles, Los Angeles, California Neil E. Grunbtxg, Ph.D., Associate Professor, Department of Medical Psychology, Uniformed Services University of the Health Sciences, Bethesda. Maryland Dudley H. Hafner, Executive Vice President, American Heart Association, Da11at, Texas James A. Harrell, M.A., Acting Director. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Washington. D.C. Jeffrey E. Harris, M.D., Ph.D., Visiting Associate Professor, Department of Biostatis- tics, Harvard School of Public Heahh, Boston, Massachusetts; Clinical Associate, Medical Services, Massachusetts General Hospital, Boston, Mapsachusetts•, As- sociate Professor of Econornics, Massachusetts Institute of Technology. Cambridge. Massachusetts 8089 18515 xiii

landmark document on smoking and health that concluded that "Cigarette smoking is the most likely cause of the recent world-wide increase in deaths from lung cancer ... is an important predisposing cause of the development of chronic bronchitis... probab- ly incrcaces the risk of dying from coronary heart disease...has an adverse effect on healing of (gastric and duodenal ( uMers ...(and) may be a contributing factor in can- cer of the mcwth, pharynx, oesophagus, and bladder." On June 1. 196 1, the presidents of the American Cancer Society, the American Public Health Assnciation, the American Heart Ac.sociation, and the National Tuberculosis Association (now the American Lung Association) urged President John F. Kennedy to establish a commission to study the health consequences of smoking. Repre- sentativcs of these organi7ations met with Surgeon General Luther L. Terry in January 1962 to reiteratc their call for action. In April, the Surgeon General presented a detailed proposal for an advisory group to reevaluate the position adopted by the Public Health Service in 1959. In calling for the advisory group. Dr. Terry cited new research on the adverse health effects of tobacco, a request from the Federal Trade Commission for guidance on policy regarding the laheling and advertising of tobacco pmducts, and the findings in the new report of the Royal College of Physicians. On July 27, 1962, following consultations between the White House and the Public Health Service, the Surgeon General held a meeting to define the work of an expert advisory group and to identify candidates for the committee. Meeting with the Sur- geon General were representatives of the American Cancer Society, the American Col- lege of Chest Physicians, the American Heart Association, the American Medical As- sociation, the Tobacco Institute, the Food and Drug Administration, the National Tuberculosis As.sociation, the Federal Trade Commission, and the President's Office of Science and Technology. The group agreed on a list of nmre than 150 scientists and physicians. Each of the organisAtions had the right to veto any of the names on the list for any reason. Persons who had taken a public position on smoking and health were not considered for inclusion on the advisory committee. Dr. Terry selected 10 individuats from the list to serve on the Surgeon General's Ad- visory Committee on Smoking and Health: Stanhope Bayne-Jones, M.D., LLD., former Dean, Yale School of Medicine; Walter J. Burdette, M.D., Ph.D., Univetsity of Utah: W illiam G. Cochrane. M.A., Harvard University; Emmanuel Farber, M.D., Ph.D., University of Pittsburgh; Louis F. Fieser, Ph.D.. Harvard University; Jacob Furth, M.D., Columbia University; John B. Hickam. M.D., Indiana University: Charles LeMaistre, M.D.. University of Texas; Leonard M. Schuman, M.D., University of Minnesota; and Maurice FI. Seevers, M.D., Ph.D.. University of Michigan. The Advisory Committee held nine meetings from November 1962 through Decem- ber 1963, during which they reviewed all the available data from animal laboratory ex- periments, clinical and autopsy studies, and rttrospective and prospective epi- demiologic studies. The Committee had access to over 7.000 publications pertaining to smoking and health, including more than 3,0(10 articles reporting research findings published after 1950. In evaluating evidence linking smoking to disease, the Commit- tec restricted judgmenk of a causal relationship to those associations for which the evidence was (I) con.sistcnt, (2) strong. (3) specific, (4) supportive of appropriate tem- pnral relationchips, atKl (5) coherent (US PHS 1964). The final Report of the Advisory Committee was released on January 11, 1964 (US PHS 1964). It concluded that "Cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarctte smoking far outweighs all other factors. The data for women, though less extensive, point in the same direction .... The risk of developing lung cancer increases with duration of smoking and the number of cigarettes smoked per day, and is diminished by discontinuing smoking." The Report also concluded that pipe smoking is causally related to lip, cancer, that cigarette smoking is causally related to laryngeal cancer in men, and that "Cigarette smoking is the most important of thecausesofchronic btonchitis " The Advisory Com- mittee identified significant associations between smoking and cancerof the esophagus, cancer of the urinary bladder, coronary artery disease, emphysema, peptic ulcer dis- ease, and low-birth-weight babies, but it did not consider the available data to be suf- ficient to label these associations causal. The Committee found that male cigarette smokers had a 70-percent exc~ss 'nortality rate over mcn who had never smoked and that female smokers also had an~elevated mortality rate, although less than that of males. The Advisory Committee concluded that "Cigarette smoking is a health hazard of sufficient importance in the l jnited States to warrant appropriate remedial action " "Remedial action" was initiated immediately after publication of ~the Advisory Committee's Report, when the Federal Trade Commission (FTC) proposed that cigarette packs and advertisements txar warning labels and that strict limitations be placed on the content of cigarette advertising. With passage of the Federal Cigarette Labeling and Advertising Act of 1965 (Public Law 89-92; amended in April 1970 by Public Law 91-222). Congress preemqed the FTC's recommendation: beginning in 1966, a congressionally mandated health waming appeared on all cigarette packs but not on advertisements. The Act also required the Secretary of Health. Education, and Welfare to submit an- nual reports to Congress on the health consequences of smoking, together with legis- lative recommendations. beginning no later than mid-1967. New reports of the Sur- geon General on smoking and health were issued in each calendar year beginning in 1967, except for 1970,1976,1977, and 1987. (In 1976, a volume of selected chapters from the 1971-75 Reports was published. The t+eport issued in 1978 was a joint Report for the years 1977 and 1978.) Thus, the present volume, commemorating the 25th an- niversary of the 1964 Report, is the 20th Report in the series. In addition, in 1986. PHS issued a report on the health consequences of using smokelass tobacco (US DHHS 1986h). Table I identifies the previous reports and highlights their coverage. The reports published since the 1964 Report have confirmed the scientific judgment of the Advisory Committee and have extended its findings. The evidence available today has reinforced the Advisory Committee's judgtnents of causality: converted most of its "significant associations" into causal retationships, adhering to the strict criteria described in the first Report; confirmed causal associations for relationships not con- templated in the 1964 Report (e.g., the health hazatds of involuntary smoking (US DHHS 19R6a)); and identified additional disease associations. Accompanying the growth and dissemination of scienlific knowledge has been in- crcased public understanding of the hazards of smoking, reflected in decreases in smok- I i 6 F 7

n (kteoporocis ..................................................... 76 Involuntary Smoking .................................... . •. 77 Smr.kelecs Tr,haeco ............................................. . 78 Acktictionto Smoking .............................................. 78 Part 11: The Physicochemical Nature of Tobacco .......................... 79 Thc Changing Cigarette ............................................ 85 Environmental Tohacco Smoke . . . . . . . . . . . . . . ........................ 88 Smokeless Tc.Mcco ................................................ 90 ToxicityandCarcinogenicityofTohaccoSmoke ........................ 92 Nic„tine . ................................................. 93 Riological Markers ................................................ 94 Summary .......................................................... 97 Conclucicros ....................................................... - - --- 100 Refercnce~ ........................................................ 102 I£g9 T851S 1i, i iNTRODUCTION The purpose of this Chapter is to summarize and compare the state of biornedical knowledge concerning tobacco and health in 1989 with that presented in the 1964 Sur- geon General's Report (see Table 13). The Chapter addresses major tobacco-related disonders that are well documented in the medical literature; it does rat consider many areas of current research that may prove to be important but are in an early or provisional state of investigation. The 1964 Surgeon General's Report was a landmark publication that includeb a sur- vey of trnxe than 7.000 available scientific articks on smoking and health. The Ad- visory Committee that prepared the 1964 Report reviewed and assessed epidemiolbgic, clinical, pathological, and experimental data for evidence linking smoking to disease. To reach conclusions concerning the causality of associations between smoking and disease, the Committee constructed a framework for evaluating the evidencel With regard to causality, the Committee concluded: ~' The causal aignificance of an association is a matler of judltment which goes beyond aey statement of statictical probability. To judge or evaluate the causal significance of the as- sociation between attribute or agent and the disea.ve, or effect upon health, a nu4ntxr of criteria must be utilized, no one of which is an all-sufficient basis for judgme4t. The.e criteria include: a) the consistenry of the ssociation b) the strength of the associatioe c) the specificity of the association d) the temporal relationships of the tmsociation e) the coherence of the associatioe (US PHS 1964). I These criteria were applied throughout the 1964 RepuR. When the word "cause" was used in the 1964 Report, it was felt to convey "the notion of a significant, effectual relationship between an agent and an associated disotder or disease in the host." Use of the word "caua" in relation to cigarette smoking did not exclude other agents as causes; rather, the rnembt:rs of the Advisory Committee shared "a common conception of the multiple etiology of biological processes." The principal findings on the health effects of smoking were stnnrnariud in the Sur- geon General's 1964 Report as follows: 1. Cigarette smoking is associated with a 70-percent increase in the age-specific death rates of men. 2. Cigarette smoking is causally related to hmg cancer in men; the magnitude of the effect of cigarette smoking far outweighs all other factors. The data for women, though less extersive, point in the same direction. 3. Civarette smoking is the most important of the causes of chronic bro6chitis in the United States and increases the risk of dying from chronic bronehitis and i 11

emphysema. A relationship exists between cigarette smoking and emphysema. but it has not been established that the relationship is causal. 4. It is established that male cigarette smokers have a higher death rate from coronary artery disease than nonsmoking males. Although the causative role of cigarette smoking in deaths from coronary disease is not proven, the Commit- tee considers it more prudent from the public health viewpoint to assume that the established association has causative meaning than to suspend judgment until no uncertainty remains. 5. Pipe smoking appears to he causally related to lip cancer. Cigarette smoking is a.ignificantfactorinthecausationofcanceroftixlarynxinmen. Theevidence supports the belief that an association exists between tobacco use and cancer of the esophagus, and between cigarette smoking and cancer of the urinary blad- der in men, tart the data are not adequate to decide whether these reiationships are causal. 6. Women who smoke cigarettes during pregnancy tend to have babies of lower hirthweight. It is not known whether this decrease in birthweight has any in- fluence on the biological fitness of the newborn. 7. Epidemiologic studies indicate an association between cigarette smoking and peptic ulcer that is greater for gastric than for duodenat ulcer. R. The habitual use of tobacco is related primarily to psychological and social drives, reinforced and perpetuated by the pharmacologic actions of nicotine. Since 1967. the U.S. Department of Health and Human Services has transmitted to the U.S. Congress mandated reports on the health consequences of smoking. Some of the reports have been encyclopedic reviews similar to the 1964 Report, whereas others have focused on the relationship between smoking and a specific topic. The Federal unit charged with preparing these annual neports, the Office on Smoking and Health, now has more than 57.000 documents on smoking and health in its Technical Informa- tion Center database. Research performed during the subsequent 25 years has substantiated and strengthened the conclusions of the 1964 Advisory Committee. Studies published since 1964 have atso established acsociations between smoking and disease in areas for which data did not exist in 1964. shed light on pathogenetic mechanisms of tobacco-related disease, and added scientific depth to areas mentioned only briefly in the 1964 Report. ~ ~'o a r ~ E Y ~ 'a Y Y > i A V >. ~ ~ d ~ wp' ~00 ao P0 O ~p- P =0,0 y o ~ .. .•S o °~ -. O n N ~O fV -~ N O O - N d a ..,M-ra_n N1 fV - O ~ 0. ~ v~ N P ~~ vl .-? aD VI O. a O g _a r N K O: g N~~ aD -! ~ N O: n n V1 N.D oa e.i e3 A O y'O t.i a _:o 1. ~. m Y ., V ~ PART I: HEALTH CONSEQUENCES 0 .o N ~ r . ~ Smoking and Overall Mortality (Cee Chapter 3 for more detailed discuqsion) ~ The ma jor prospective studies of the disease risks associated with smoking completed in the IWA)s and I970s contributed substantially to an underaanding of the relation- ship between smoking and disease (US DHi:W 1979). These studies provided es- timatcs of both the relative and attrihutahlc risks related to cigarette and other types of smoking (Table 1) (US DHEW 1979). Male cigarette smnkers had approximately 7() percent higher overall death ratcs than rnmsmokcrr the excess mortality of female 5 :. r 4~r 5$y~ Vf [+ g > _ „Is G ., ~~ 'A r. ~. . . ' ~ 0 O O O o 0 0 0 0 0 0 2 y Q y C C .`y$ye$ u uyt uy`ut uy v~ p 3` C tS 1' u U V U uVC~lVUV VU- UV QSC7 < ~ Yp ~ ~, ^ n a, a=~==x .~ 1 Z£89 tBStS ~t ix