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THE HEALT- ~ T--11 all aE.'sQu E"K -4 CILEJ ~~ 0 ~~`~~~i~ 2'0a WOMEN a report of the Surgeon General THIS REPORT CONTAINS SOM E TECHNICAL ERRORS. AN ERRATA SHEET TO FOLLOW SHORTLY r4: s U.S. DEPARTMENT OF HEALTH. EDUCATION, AND WELrARE Public Health Service Office of the Assistant Secretary for Health Office on Smoking and Health . TIMN 0048200

TNE sECRETART OF NEAITN, EOUCATION,ANO WEIFARE WA3N 1 N OTON, O. C. 20201 The Honorable Thomas P. O'Neill,Jr. Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: I hereby submit the 12th annual report that the Department of Health, Education, and Welfare (DHEW) has ;pr,epared for Congress as required by the Public Health Cigarette Smoking Act of 1969, Public Law 91-222, and its predecessor, the Federal Cigarette Labeling and Advertising Act. This report is one of the most alarming in the series. It clearly establishes that women smokers face the same risks as men smokers of lung cancer, heart disease, lung disease and other consequences. Perhaps more disheartenieYg is the harm which mothers' smoking causes to their unborn babies and infants. The report is not all bad news. It presents recent data showing that women are turning away from smoking in response to the warnings of government, voluntary agencies and physicians. The precipitate rise in women's deaths from lung cancer and chronic lung disease demand that this trend away from cigarettes be accelerated. our scientists expect that by 1983, the lung cancer death rate will exceed that of any other type of cancer among women. Citizens of our free society may decide for themselves whether to smoke cigarettes. The health consequences of this decision make it imperative for their government to assure that the decision is an informed one. This series of reports is one way in which DHEW is striving to meet this critical responsibility. /J s Patricia Roberts Harris s TIMN 0048201

PREFACE This report is more than a factual review of the health consequences of s?noking for women. It is a document which challenges our society and, in particular, our medical and public health communities. This report points out that the first signs of an epidemic of s,noking-related disease among wornen are now appearing. Because women's cigarette use did not become widespread until the onset of World War II, those women with the greatest intensity of smoking are now only in their thirties, forties, and fifties. As these women grow older, and continue to smoke, their burden of smoking-related disease will grow larger. Cigarette smoking now contributes to one- fifth of the newly diagnosed cases of cancer and one-quarter of all cancer deaths among women--more cancer and more cancer deaths among women than can be attributed to any other known agent. Within three years, the lung cancer death rate is expected to surpass that for breast cancer. A similar epidemic of chronic obstructive lung disease among women has also begun. , Four main themes e -nerge from this report to guide future public health efforts. First, women are not immune to the dama.-ing effects of smoking already documented for men. The apparently lower susceptibility • to smoking related diseases among women smokers is an illusion reflecting the fact that women lagged one-quarter century behind men in their widespread use of cigarettes. Second, cigarette smoking is a major threat to the outcome of pregnancy and well-being of the newborn baby. Third, women may not start smoking, continue to smoke, quit smoking, or fail to quit smoking for precisely the same reasons as men. Unless future research clarifies these differences, we will find it difficult to prevent initiation or to promote cessation of cigarette smoking among .vomen. Fourth, the reduction of cigarette smoking is the keystone in our nation's long term strategy to promote a healthy lifestyle for wo;,en and men of all races and ethnic groups. i 4 TIMN 0048202 `

THE FALLACY OF WOMENIS IMMUNITY All of the major prospec.'ive studies of smoking and mortality have reached consistent conclusions. Death rates from coronary heart disease, cironic lung disease, lung cancer, and • overal l mortality rates a,e significantly increased among both women and men smoker--,. . These risks increase with the , amount smoked, duration of smoking, depth of inhalation, and the "tar" and nicotine- delivery of the cigarette smoked. In these studies, condacted during the past three decades, relative mortality risks among female, smokers appeared to be less than those of male smokers. It is now clear, however, that these studies were comparing the death rates of a generation oti established, lifelong male smokers with a, generation of women who had not yet taken up smoking with full intensity.. Ev-_.n, 'those older women who reported smoking a large, number of cigarettes per day had not smoked cigarettes in the. . sarne WLy as their male counterparts. Now that the cigarette smoking characteristics of women.and men are becoming increasingly similar., their relative. risks of smoking-relited illness w.ll become. increasingiy, similar. This fallacy of w.)men's apparent immunity. is clearly il lustrated ,by differences in the .timing of. :the growth i1 , lung cancer among men and women in this ;'century. . Lung= cancer deaths among males began to increase during the 1930.s,. as those men who had conve •ted from other. forms of tobacco to cigarette smoking before- the_.turn of the century gradually :accuniulated decades of . inhaled -tobacco, exposure. : By the time of ..the first retros~iective studies of smoking"`and lung cancer in .1950, two ent ire generations. of . men had already become lifelong cigarett=: smokers. Relatively few -women from these generations siroked cigarettes, .and even fewer had smoked cigarettes. since their -adolescence. Those young wornen who had taken up smoking intensively during, World War .11 were..onty 'in their twenties and thirties. In 1950, women accounted' r for less than one n in twelve. deaths from lung cancer. Thereafter, the aae* adjusted lung cancer death rate among women accelerated, and the male predominance in lung cancer declined. Lung cancerr surpassed uterine cervical cancer as a cause of d-;ath in women. By 1968, as the findings of many large population . prospective studies were being published, women accounted for one.-sixth of all lung - cancer •deaths. These ;studies found that women cigarette smokers had 2.5 to. 5 Vnes greater death rates from lung ® - -----y--~

cancer than wo-nen nonsmokers. By 1979, women accounted for fully one-fourth of all lung cancer deaths. Over the next few years, women cigarette smokers' risk of lung cancer death will approach 8 to 12 thnes that of women nonsmokers, the same relative risk as that of inen. Lung cancer has four main histological types: epider.noid, small cell, adenocarcinoma, and large cell carcinoma. As several studies have shown, the incidence of each of these types of lung cancer displays a clear relationship to cigarette smoking among both men and women. Epider!noid and small cell lung cancer appear to be more prominent among men, while adenocarcinoma of the lung now appears to be more prominent among women. The recent acceleration of lung cancer incidence among women has in fact been more rapid than the corresponding growth of lung cancer among men in the 1930s. Again, this difference in the initial rate of acceleration of lung cancer incidence does not refute the demonstrated causal relation between cioarette smoking and lung cancer among both sexes. Instead, differences in the rate of increase of lung cancer incidence may reflect changes in the carcinogenic properties of cigarette smoke, the style of cigarette smoking, or the interaction of cigarette smoking with other environmental hazards. It is noteworthy that those men who died of lung cancer in the 1930s came from a -eneration that had gradually ` converted to cigarettes from other, non-inhaled forms of tobacco. By contrast, the first regular tobacco users amono wo:nen were almost exclusively cigarette smokers. The 1979 Report on Smoking and Health documented nu:merous instances where cigarette smoking adds to ' the hazards of the workplace environment among men. Among, women, this report reveals two such occupational exposures-- asbestos and cotton dust--which have been clearly demonstrated to interact with cigarette smoking. The fact that evidence is limited among women does not imply that wonen are protected from the dangerous interactions of smoking and occupational exposures. PREGNANCY, INFANT HEALTH, AND REPRODUCTION Scientific studies encompassing various races and ethnic groups, cultures and countries, involving hundreds of thousands of pregnancies, have shown that cigarette smoking during pregnancy significantly affects the unborn fetus and the i i i . TIMN 0048204

the newborn baby. - These damaging effects have been repeatedly shown to operar,e independently of all other factors which influence the outco.ne of pregnancy. The effects are increased by heavier smocing and are reduced if a woman stops smoking during preg;:aney. • Numerous toxic substances- in cigarette smoke, such as nicotine and hydrogen cyanide, cross the placenta to affect the fetus directly. The ca_rbon monoxide from cigarette smoke is transported into the fetal blood, and deprives the growing. baby of oxygen. Fetal growth is directly retarded. The resulting reduction in retal weight and size has many unfortunate- consequences. Women who smoke cigarettes during piegnancy have more spontaneous abortions, and a greater incidence of bleeding during pregnancy, premature and prolonged rupture of amniotic membranes, abruptio -placentae and • placenta previa. W_,men who smoke cigarettes during pregnancy have. more `etal and neonatal deaths- than nonsmoking pregnani wom-;n. A relation between maternal smoking. and Sudden Infa it Death Syndrome • has now been estabiished...:.... The". direct''-harmful effects of smoking on the fetus have"long. term • consequences. Children - of mothers who smoked during pregnancy lag 'measurably In physical growth; there. • may~ also be : ef Pects on " behavior and"cognitive development. The oextent )f these deficiencies increases with the number of. cigarettes smoked.'' - "The damaging".effe.-ts 'of '.maternal smok.ing on infants are not restricted to preg.ancy: _ -Nicotine; a known poison,. is found in- the breast milk of smoking mothers. Children whose parents smoke cigarettes have more respiratory infections and more hospitalizations• in th3 first year of life. Women' who smoke cigarettes - have more than three times the risk of, dyino of ' stroke due to subarachnoid hemorrhage, and as much as two times the risk of dying of heart • attack in comparison • to nonsmoking women. 7he use of oral contraceptives in addition to smoking; however,• causes a markedly increased risk, iicluding a 22-fold increase, in the risk of subarachnoid heinorrhagic stroke and -, a 20-fold increase in heart attack in heavy smokers. WHY DO WOMEN SMOKE? Cigarette consumption in this country is now declining. Annual per capita consu:np;ion has decreased from 4,258 in

1965 to an estimated 3,900 in 1979. From 1965 to 1979, the proportion of adult male cigarette smokers declined from 51 to 37 percent. idot only have millions of men quit 00 ai' smoking, but the rate of initiation of smoking among adolescent males has now slowed. Frofn 1965 to 1976, the proportion of adult women cigarette smokers remained virtually unchanged at 32 to 33 percent. Since 1976, however, the proportion of adult rvornen cigarette smokers appears to have declined to 28 percent. Although adult woraen are now beginning to quit smoking at rates comparab,le to' adult men, the rate of initiation of smoking among younger women has not declined. This report documents numerous differences by sex in the perceived - role of cigarette smoking, in attitudes toward health and lifestyle, and in methods of coping with stress, anger, and boredom. Yet the significance of these differences, and their relation to differences in smoking patterns, remains poorly understood. Although it is frequently observed that women in or,o,anized smoking cessation programs have more severe withdrawal symptoms and lower rates of successful quitting than men, these observations have not been systematically confirmed for the general population. In the past, women pted to quit or succeeded in quitting s:noking may have atte,n less frequently than rnen. The recent decline in the propor- tion of women smokers, however, suggests that women's attempted and successful quitting rates have now increased. Although weight vain is a frequently cited consequence of quitting smoking, the association of weight gain with cessation of smoking has not been the subject of sufficient scrutiny. Controlled studies with careful measurement on representative populations of women do not exist. The impact of the fear of weight gain after quitting has not been ade- quately examined. If weight gain does result from cessation of smoking, its exact mechanism must be determined. Even more problernatic are marked differences by sex in the distribution of smoking prevalence by occupation. Men with advanced education and professional occupations have taken the lead in quitting smoking, but wo:nen in administrative and managerial positions have relatively high smoking prevalence rates. Although 20 percent or fewer male physicians smoke, the proportions of cigarette smokers among women health professionals, especially nurses and psychologists, remain disturbingly high. Recent changes in smoking prevalence among black V TIMN 0048206

women and men have p-iralleled those of the general population. From 1965 to 1979, the proportion of black women cigarette smokers -ieclined• from 34 to 29 percent, while the proportion of black men smokers declined from 61 to* 42_•percent. ._ However, differences by race in the onset, maintenance, and cessation of smoking have not been adequately °•explored. Little is known about cigarette smoking among other ethnic and min•)rity groups. ADOLESCENT SMOK1 NG •' ' The' health "consequences oi' 's;noking evolve - over a lifetime. Evidence continues to accuwulate, for example, that cigarette smoking_produces measurab e lung changes' even in childhood ind-young-aduithood. Youn g cigarette smokers •of bottr sexes show more evidence 'of small 'airway dysfunction, and a higher prevalence of cough, wheezing, • phlegm production, and other '•respiratory^ symptoms. Th-: health damage due to cigarette smoking increases when an individual -beg•ins regular smoking earlier in life. Yet, as this report documents, the average age of onset of regul ir smoking among '-women ' has, continuously declined durin_; the last '50 years,'"and continues to• decline. ' " According to a recestt survey by the National Institute :of Education, cigarette smoking among adolescent girls now -exceeds that among adolescent boys: In the 17-19 year' age group, there are almost 5--emale cigarette smokers for every 4"male • cigarette smokers. • The causes of this inversion are far from clear. 1ille do -not' yet• understand the signal events in *the initiation of smok ing among young women. It is possible that parents set e=ampies concerning lifestyle, health attitude, and risk-taking much earlier in childhood. The beginning of• junior high -;chool or entrance into the work force may be equally critical events. We do not know enough about an adolescent's sens_ of competence and self-mastery, and how these roles differ among women and men. Although smoking patterns among girls correlate with parental, peer and sibling smoking habits, educational level, type of school curriculum, academic performance, socioeconomic ' status, and other forms of substance 2buse, the practical significance of these empirical correlations is unclear. vi --.--~ ® i--~~ -- .,~.__ ._._._.._... ->. ;...~= ~... ® ® - _~-~-~-~ .............. r..:_.._._.._ -

VJON1EN AND THE CHANGING CIGA;ZETfE As this report docu:nents, the proportion of men and women smokers using brands with lowered "tar" and nicotine continues to grow. Adolescents of both sexes have followed this trend, to the point where nonfilter cigarettes are relatively rare among young adults. Although the preponderance of scientific evidence continues to suggest that cigarettes with lower "tar" and nicotine are less hazardous, four serious warnings are in order. First, the reported "tar" and nicotine deliveries of cigarettes are standardized machine measure;nents. They do not necessarily represent the smoker's actual intake of these substances. Evidence is now ~nounting that individuals who switch to cioarettes with lowered "tar" and nicotine •inhale more deeply, smoke a great,er proportion of their cigarettes, and in some cases smoke more cigarettes. Second, "tar" and nicotine are not the only dangerous chemical components of ci`arette smoke. Many conventional filter cigarettes, in fact, may deliver -nore carbon monoxide than nonfilter cigarettes. Third, it has not been established that lower "tar" and nicotine cioarettes have less harmful effects on the unborn fetus and•baby; on women and men at high risk for developing - coronary heart disease, such as those with elevated cholesterol or high blood pressure; or on workers with adverse occupational exposures. It has not been established that switching to a lower "tar" and nicotine cigarette has any salutory effect on individuals who already have smoE;ircgm- related illnesses, such as coronary heart disease, chronic ' bronchitis, and emphysema. Fourth, even the lowest yield cigarettes present health hazards for both women and men that are very much higher d than smoking no cigarettes at all. The single most effective way for both women and men smokers to reduce the hazards associated with cigarettes is to quit smoking. As this report demonstrates, little is known about the effects of these product changes on the initiation, maintenance and cessation of smoking, particularly among women. It has not been determined whether the availability of cigarettes with lowered "tar" and nicotine has made it easier for young women to experiment with and beconne addicted to cigarettes. It is not known whether smokers of vii TIMN 0048208

the iowest yield cigarettes are more or less likaly to attempt ~ to..--qut,, or to- succe-sd in, quitting, than smokers of conventional filtertip or nonfilter cigarettes. The extent to which the act of switch ing to a lower 11tar" cigarette may serve as a substitute fo r quitting may differ among women and men. PUBLIC HEALTH RESPONSIBILITIES This report, which includ=;s data compiled by individuals from both-- ,ins%de and outside the Government, has confirmed in every_ wa.y the judge:nent of the World Health Organization, that there can no longer be any doubt among informed people that cigarette smoking is a major and removable cause of ill health and "premature death. Each individual woman must make her own decision about this significant health issue. Secretary Harris has noted that, the role of the Government, and , all responsible health professionals, Is ':o assure that this decision is an Informed one. In issuin_; this report, we hope to help the public health community' a.:complish this purpose. Julius. B. Richmond, M.D. Assistant Secretary for •. Health and Surgeon Gener1l