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ACicNOwLEDGEMENTS This report was prepared by agencies of the U.S. Department of Health, Education and Welfare under the general editorship of the Office on Smoking and i-iealth, f ohn IM. Pinney, Director. Consulting scientific editors were David M. Burns, Assistant Clinical Professor, Pulmonary Division, University of California at San Diego, San Diego, California and John H. Holbrook, M.D., Assistant Professor of Internal Medicine, University of Utah Medical School, Salt Lake City, Utah. ' Introduction and Summary Office on Smoking and Health Patterns of Cigarette Smoking Office on Smoking and Health Jeffrey E. Harris, M.D., Ph.D., Assistant Professor, Department of Economics, Masasachusetts Institute of Technology, Cambridge, Massachusetts; Clinical Assoeiate, Medical Services, Massachusetts General Hospital, Boston, Massachusetts. Overall Mortality National Heart, Lung, and Blood Institute Eugene. Rogot, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, 'vlaryland; Thomas J. Thom, Division of Heart and Vascular Diseases, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland Morbidity National Center for Health Statistics Ronald W. Wilson, M.A., Chief, Health Status and Demographic Analysis Branch, Division of Analysis, + National Center for Health Statistics, Hyattsville, Maryland. Cardiovascular Diseases National Heart, Lung, and Blood Institute. G.C. McMil/an, M.D., Ph.D., Associate Director for Etiology of Arteriosclerosis and Hypertension, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of t-lealth, Bethesda, Maryland. xi 210 r.UIMN 004

Cancer National Cancer Institute ~ ~ Jesse L. Steinfeld, M.D., Dean, Medical College of Virginia, Richmond, Vi rginia. Non-Neoplastic Broncilopulmonary niseases •National Heart, Lung, and Rlood Institute Richard A.. ' Pordow, M.D., Associate Research Physiologist, 'Univers4iy of California at San nPeRo, San Diego•, 'California;-•Claude J'.M: Lenfant, M.D., Director, Divisiort of Lunj Disease, National Heart, Lung, 'and' Riood Institute, National Institutes of Health, gethesda; Maryland • Barbara Marzetta Liv, Division of Lung Disease, National Heart, Lung, 'and Rlood (nstitute, I nstitutes of ' Health, [? ethesda; 'Maryiand National Eric R. Jurrus, Division "of Lung- Disease, National : Heart, Lung,•• and Bloo i Institute, National - Institutes of ` Health, Bethesda, M;ryiand. . irttei'action ' Between Smoking and nccupatiortal • . Exposures '. -s - , •` National •Institute •of O-:cupational Safety and Health + jeanrte= •Steelman, = Ph:D., American 'Health = Foundation, •New York,, New° York ° Steven D. Stellman, Chief, Division' of Health & Toxicology, ° American 'Nealth ' 'Foundatiort, •New •York, `4New'~'ork' : . ' ' Pregnancy •. and Infant H-;alth• '' ' . 'NYtionai`. Institute of Child Development•:' :` Health and • Human Eileen G. Hasselmey-sr, Ph.D., R.N., Associate 'birector - for ~ Scientific'• Review, National Institute of °`- Child ' Health ` •and` •, H.iman ' Development, • National '1•nstitutes of Health, •Re-,hesda 'Maryland. • Mary '~:Meyer, .' Associate Professor of Epidemio'logy; ' Johns - Hapkins University °School of Hygiene and Public Heal th, Paltimore, Maryland. - Lawrence D. Longo, M.D=, Professor of Physiology and '-nbstertrics and' Gynecology,- •Loma ~Linda University School of Medicine, Lom i Linda, California - . • Donaid R. +• Mattison, ` M.D., • Senior Investigator, Pregnancy : Research Pranch, National Institute of Child • Health• and'. Human- Development, National %' 1 nstitutes of Health, Betilesda, Maryland. dictL}14 VtAI'''Ji1VL

Peptic Ulcer National Institute of Arthritis, Metabolism and Digestive Diseases Travis E. Solomon, M.D., Ph.D., Center for Ulcer Research and Education, VA Wadsworth Medical Center and UCLA School of Medicine, Los Angeles, California Janet Elashoff, Ph.D., Center for Ulcer Research and Education, VA Wadsworth Medical Center and UCLA School of Medicine, Los Angeles, California. Interactions of Smoking with Drugs, Food Constituents and Responses to Diagnostic Tests Cheryl Fossum Graham; Division of Drug Experience, Office of Biomet•rics and Epidemiology, Bureau of Drugs, Food and Drug Administration. Psychosocial and Rehavioral Aspects of Smoking in Women Initiation, Maintenance, and Cessation Ellen R. Gritz; Ph.D., Research Psychologist, Veterans Administration Medical Center, Rrentwood, California and Associate Research Psychologist, Department of Psychiatry and Fehavioral Sciences, School of Medicine, University of California, Los Angeles, California. Ann 'Frunswick, Ph.t?., Senior Research Associate . (Sociomedical Sciences), Center for Sociocultural Research on Drug Use, School of Public Health, Columbia University, New York, New York. Karen L. Bierman, M.A., C?epartment of Psychology, University of California, Los Angeles, California. The editors acknowledge with gratitude the many distinguished' scientists, physicians, and others who assisted in the preparation of this report by coor- dinatinfg manuscript preparation, contributing criti- cal reviews of the manuscripts or helping in other ways. Elvin A. Adams, M.D., M.P.H., Practicing Internal Medicine, Fort Worth, Texas. Josephine D. Arasteh, Ph.D., Health Scientist Administrator, Human Learning and Behavior Rranch, Center for Research for Mothers and Children, National Institute of Child Health and Human . TIMN 0048212

Development, National Institutes of Health, Rethesda, M aryiand. Lester Breslow, M.D., M.P.H., Dean, School of Public Health, University of California at Los Angeles, Los Angeles, California. A. Sonia Buist, M.D., Associate Professor of Medicine & Physiology, University of Oregon Health Sciences Center, Portland, Oregon. David M. Rurns, M.D., Assistant Clinical Professor, Pulmonary Division, University of California at San , Delgo, San Diego California. Thomas C. Chalmers, M.D., President and Dean, Mount Sinai Medical Center, New York, New York. ' Florence L. Denmark, Ph.D., Professor of Psychology, i Ph.D. Programs in Psychology, City University of New f York, New York, New York.._ Robert M. Donaldson, Jr., M.D., Chief, Medical Services, Westhaven Veterans Hopitai, Westhaven, Connecticut. ", Joseph T. Doyle, M.D., Professor of Medicine and Head, Division of Cardiology of the Department of Medicine, Albany Medical College of Union University, Albany, New York. Elizabeth M. Earley, Ph.D., Chief, Section of Cytogenetics, Division of Pathology, Rureau of Biologies, Food and Drug Administration, F?ockvilie, Maryland. f Bernard H. Ellis, Jr., Program Director for Smoking ; and Occupational Activities, Office of Cancer al Natio er t Natio l Ca stit te i ti ~' C nc n , n ommun ca ons, na u i nstitutes of Health, Bethesda, Maryland. Diane Fink, M.D., Associate Director, Medical Applications of Cancer Research and Coordinator, Smoking, Cancer, and Health Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland. Harold E. Fox, M.D., Associate Professor of Clinical ; Obstetrics and Gynecology, Deoartment of Obstetrics and Gynecology, Columbia Presbyterian Medical Center, and Medical Director, Western and Upper Manhattan Perinatal Network, New York, New York. Joseph H. Gainer, D.V.M., Veterinary Medical Office, Division of Veterinary Medical Research, Bureau of Veterinary Medicine, Food and Drug Administration, ; Rockville, Maryland. xiv T7MN 0048213

Stanley N. rershoff, Ph.n., Director, `!utrition Institute and rhairman, rraduate nepartment of Nutrition, Tufts University, ~Aedford, Massachusetts. Sharon 'A. Hall, Ph.!?., Assistant °rofesscr, University of California at San Francisco, Lanaley Porter Neuropsychiatric Institute, San Francisco, California. Jane Halpern, M.n., ASPER, Office of Health and Disability, United States Department of Labor, Washington, D.C. Reatrix A. Hamburg, Research Psychiatrist, Laboratory of Development Psychology, National lnstitute of Mental Health, National Institutes of Health, Rethesda, Maryland. Virginia G. Harris, M.D., Director, Maternal and Child Health, Onondago County Health Department, Syracuse, New York. John H. Holbrook, tiA.D., Assistant Professor of Internal Medicine, University of Utah `"edicat School, Salt Lake City, Utah. , Stanley James, M.D., Professor of Pediatrics, Obstetrics, and Gynecology, College of physicians and Surgeons, Columbia Preshyterian Medical Center, New York, New York. Hershel Jick, M.n., noston Collaborative Drug Surveil-lance Program, Boston University PRedical Center, Waltham, Massachusetts. Reese T. Jones, "".n., Professor . of Psychiatry, Department of Psychiatry, University of California at San Francisco, Langley Porter Neuropsychiatric Institute, 'San Francisco, California. Philip Kimbel, -~".1?., Head, Pulmonary niseases Section, Albert Einstein ft4edical Center, Philadelphia, Pennsylvania. Jan '0/. Kuzma, Ph.ll., Chairman and Professor of Biostatistics, Department of Riostatistics and Epidemiology, Loma Linda University, Loma Linda, California. Abraham Lilienfeld, M.D., M.P.H., O.Sc.,University Distinguished Service Professor, Jot+ns Hopkins School of Hygiene and Public Health, Raltimore t1aryiand. Harold A. Menkes, M.D., Associate Professor of P4edicine, Department of Medicine, Johns Hopkins University, Raltimore, Maryland. Kenneth A"oser, M.D., Professor of Medicine and xv ,_ - ,.~ AQ,7.14

Director, Pulmonaiy Division, University of California, San Diego, California. Mariquita:AFMuilan, N-itional Institute of Occupational Safety and Health, R)ckvil le, Maryland. Janyce E. Notopoulo-;, Program Analyst, Office of Planning and Eval iation, National Institute of Child Health and Human f•)evelopment, National 1 nstitutes of Health, Bethesda, Maryland. Albert Oberman, M.D., . Director, Division of Preventive Medicine, School of Medicine, University of Alabama,. Rirminghim, Alabama. Ralph S. Paffenberger, Jr., M.D., Professor of Epidemiology, Depa,•tment o.f Health Services, California State Health Department, Berkeley California. . Richard Peto, - M_0., Radeliff Clinic, Oxford University, Oxford, E,rgland. Malcolm C. Pike, PFi.D., Professor, Community and Family Medicine, S-:hool of Medicine, University of Southern California at Los Angeles, Los Angeles, California. . Ovidt R. Pomerleau, Ph.D., Professor of Psychology and Ps.yohiatry,. Univ-rrsity of Connecticut School of Medicine, Farmington, Connecticut. Phi!! H. Price, M_r),, Chief, Metabolic Products Branch, Division of Ruminant Species, Bureau of Veterinary Medicine, Food and nrux Administration, Rockville, Maryland. Mrs. Dorothy Pechman Rice, Director, National Center for Health •Statisti•;s, Office of the Assistant Secretary for, Health. Hyattsvile, Maryland. Anthony Robbins; M-i i., Director, National Institute of Occupational Safety and Health, Center for nisease Control, Rockvil le, Ma -yland. - . Harold P. Roth, M.D,$ Associate Director for Digestive Diseases & Nutrition; National Institute of Arthritis, Metabolis,ti, and Digestive Diseases, National Institutes of Health, Bethesda, *Maryland. Philip Sapir, Special Assistant to the Director for Behavioral and Socia l Sciences -and Chief, Human Learning and Pehavior-ii Branch, Center for -Research for Mothers and Children, National Institute of Child Health and Human Devetopment, National Institutes of Health, Bethesda, Maryiand. Marvin A. Schnieder.ma-i, Ph.D., Associate Director for ,.~._,.,._~....~.a.., : ~ .u.•.: .;-.--..- . ........ T _ ~., ~

Scieoce Policy, National Cancer Institute, National Insti[utes of Health, Pethesda, k'arviand. I rvin;t J. Setikoff, M.D., Professor, Mount Sinai Merli,.at Center, New York, New York. S. i. Shihko, Ph.D., Chief, Contaminants and Natural Toxicants Pranch, Division •of Toxicology, Rureau of Foods, Food and Rrug Administration, P.ockville, Maryl=.nd. Jeremiah Stamler, Chairman, Department of Community Health and Preventive Medicine, ' Northestern Univer-;ity Medical School, ChicaAo, Illinois. Jesse Steinfeld, M.D., Dean, Medical College of Virgini:t, Richmond, Virginia John ,. Vanderveen, Ph.D., Director, Division of Nutrition, Rureau of Foods, Food and nrug Administration, Rockvitle, Maryland. Eve W= inhlatt, Assistant Director, Department of Researc7t and Statistics, Health Insurance Plan of Creater New York, New York, New York. Samuel S. C. Yen, Rl.n., Professor and Chairman, DepartmOnt of Reproductive Medicine, University of [:alifcrnia, San Diego, LaJolta, California. The editors also acknowledge the heiE, of the following staff who among others assisted in the preparation of the reoort. John L. pagrosky, Acting Associate Director for Program Operations, Office on Smoking and Health, Rockviile, Maryland. Jacauetine 0. Rlandford, Clerk-Typist, Office on Smoking and Health, Rockville, Maryland. Petty Rud,,, Secretary (TypinP), Office on Smoking and Health, Rockvilie, Marvland. John F. Hardesty, Jr., Public information Officer, Office on Smoking and Nealtb, Rockville, Marvtand Patricia E. Healy, Clerk (Typing), Office on Smoking and t-iealth, Rockvilie, Maryland. Douglas T. Howard, Jr., Ph.D., Senior Editor, Koba A ssociates, Washington, D.C. Robert S. Hutchings, Associate Director for i nformation and Program t,evelopment, Office on Smoking and Health, Rockville, Maryland. Margaret E. :Cetterman, Secretary (Typing), Office on Smoking and aeatth, Rockville, Maryland. xvii 4

Richard A. Lasco, Ph.D., Rureau of Health, Education, nter for_,,,Disease. Control, Atlanta, Georgia. Ce, Frances Lazerow, Vice-President, Koba Associates, Washington, D.C. Joanne Luoto, M.D., M.P.H. Medical Office, Office on Smoking and Health, Rockville, Maryland. Jack R. Maples, Senior Research Associate, Koba Associates, Washington, D.C. _ Marianne R. McCarthy, Pt+.Ll., Director of Technical Support Services, Koha Associates, Washington, D.C. Marjorie L. Olson, Secretary (Stenography), •Office on Smoking and Health, Rockville, Maryland. Keiley __L.,_Phillips, M.D., AR.P.H., Expert Consultant, Office on Smoking and Health, Rockville, Mayland. David L. Pitts, Public Health Advisor, Operations Praneh, Nutrition Division, Rureau of Smallpox Eradication, Center for nisease Control, Atlanta, Georgia. Donald R. Shopland, Technical Information Officer, Office on Smoking and Health, Rockville, Maryland. Linda R. Spiegeiman, Administration Assistant, Office on ,°moking and Health, Rockville, Maryland. Carol M. Sussman, Technical Publication Writer/Editor, Office on Smoking and Health, Rockville, Maryland. Ronald G. Thomas, Public Health Analyst, Office on Smoking and Health, Rockville, Maryland. Selwyn M. WainRrow, Public Health Analyst, Office an Smoking and Health, Rockville, Maryland. Ann E. Wessel, Public Health Analyst, Office on Smoking and Health, Rockville, Maryland. Carole L. Winn, Assistant Chief, Clinical Chemistry Standardization Section, Clinical Chemistry Division, Metabolic Plochemistry Rranch, Pureau of Laboratories, Center for Disease Control, Atlanta, Georg ia. TIMN 0048217

CONTJVTS INTRODUCTION AND SIAtAARY ............................t PART I .x . PATTERNS OF SMDK I NG AMCNG W+CMEN AND MEN I N THE UNITED STATES, 1900 - 1979 ....................1S The Rise of Cigarette Smoking: 1900-1950 ......................17 The Emergence of Filtertip Cigarettes: 1951-1963......... 24 Increasing Public Health Awareness: 1964-1979..........25 Exposure to Cigarette Smoke Among Successive Birth Cohorts .........................31 Cigarette Smoking Asnong Women...37 Sunmary ......................... PART II BIOh1EDICAL ASPECTS OF SMOKING OVERALL MORTALITY ...........................53 Mortality Trends.......................53 Epidemiological Studies ................5$ American Cancer Society 25 - State Study ....................58 Swedish Study ...................60 Canadian Veterans Study......... 60 Japanese Study of 29 Health Districts ......................60 British Doctors Study...........61 Framingham Heart Study..........61 British - Norwegian Migrant Study ..........................62 Overall Mortality For Females-Cigarette Smokers versus Non-Smokers............ 63 Mortality Ratios ................63 Amount Smoked and Age........... 63 Duration of Smoking .............72 i r r xix t TIMN 0048218

., / , N®N®NEOPLAST I C BRONCPiOPUI.ArtCNARY D I SEASES ........... 160 Definitions .......................•....160 Smoking and Respiratory "Aortaiity...... 161 Smoking and the Epidemiology and Pathology of Chronic Obstructive Lung Disease ............................... 166 Smoking and Respiratory PAorbidity...... 173 Smoking and Pulmonary Function.........182 Smoking and nEarly" Functional Abnormalities ..................183 Smoking and Ventilatory Function .......................187 INTERACTION BETWEEN SMOKING AND OCCUPATIONAL EXPOSURES .........................................203 P REGNANC."Y Smoking Patterns in tii/omen ..............204 Patterns of a•nployment.................208 The Reproductive Role ..................213 Specific Interactions Between Occupational Exposure'and Smoking.....215 Asbestos ........................215 Cotton Dust .....................218 AM INFANT HEALTH ........................224 Smoking, Birth Weight, and Fetal Growth ................................224 Placental Ratios ................226 Gestation and Fetal Growth......229 Long Term Growth and Development ................................230 Role of Maternal Weight Gain....237 Smoking Fetal and Infant Mbrtal ity and Morbidity .............................243 Spontaneous Abortion............ 243 Congenital Malformations........ 245 Perinatal Mortality .............250 ; Cause of Death................... 252 Complications of Pregnancy and Labor...254 Preeclamsia .....................256 Preterm Delivery, Pregnancy Complications and Perinatal Mortality by Gestation........ 258 Long Term Morbidity and Mortality...... 263 Sudden Infant Death Syndrome....266 xxi TIMN 0048220