Tobacco Documents Online

This Report should galvanize the health community to stress repeatedly at every opportunity the value of smoking cessation to the 50 million Americans who continue to smoke. James O. Mason, M.D., Dr.P.H. William L. Roper, M.D. Assistant Secretary for Health Director Public Health Service Centers for Disease Control ui TIMN 438387

PREFACE This Report of the Surgeon General is the 21st Report of the U.S. Public Health Service on the health consequences of smoking and the first issued during my tenure as Surgeon General. Whereas previous reports have focused on the health effects of smoking, this Report is devoted to the benefits of smoking cessation. The public health impact of smoking is enormous. As documented in the 1989 Surgeon General's Report, an estimated 390,000 Americans die each year from diseases caused by smoking. This toll includes 115,000 deaths from heart disease; 106,000 from lung cancer; 31,600 from other cancers; 57,000 from chronic obstructive pulmonary disease; 27,500 from stroke; and 52,900 from other conditions related to smoking. More than one of every six deaths in the United States are caused by smoking. For more than a decade the Public Health Service has identified cigarette smoking as the most important preventable cause of death in our society. It is clear, then, that the elimination of smoking would yield substantial benefits for public health. What are the benefits, however, for the individual smoker who quits? A large body of evidence has accumulated to address that question and derives from cohort and case-control studies, cross-sectional surveys, and clinical trials. In studies of the health effects of smoking cessation, persons classified as former smokers may include some current smokers; this misclassification is likely to cause an underestimation of the health benefits of quitting. Taken together, the evidence clearly indicates that smoking cessation has major and immediate health benefits for men and women of all ages. Overall Benefits of Smoking Cessation People who quit smoking live longer than those who continue to smoke. To what extent is a smoker's risk of premature death reduced after quitting smoking? The answer depends on several factors, including the number of years of smoking, the number of cigarettes smoked per day, and the presence or absence of disease at the time of quitting. Data from the American Cancer Society's Cancer Prevention Study II (CPS-II) were analyzed in this Report to estimate the risk of premature death in ex-smokers versus current smokers. These data show, for example, that persons who quit smoking before age 50 have one-half the risk of dying in the next 15 years compared with continuing smokers. Smoking cessation increases life expectancy because it reduces the risk of dying from specific smoking-related diseases. One such disease is lung cancer, the most common cause of cancer death in both men and women. The risk of dying from lung cancer is TIMN 438388 v

FOREWORD More than 38 million Americans have quit smoking cigarettes, and nearly half of all living adults who ever smoked have quit. Unfortunately, some 50 million Americans continue to smoke cigarettes, despite the many health education programs and anti- smoking campaigns that have been conducted during the past quarter century, despite the declining social acceptability of smoking, and despite the consequences of smoking to their health. Twenty previous reports of the Surgeon General have reviewed the health effects of smoking. Scientific data are now available on the consequences of smoking cessation for most smoking-related diseases. Previous reports have considered some of these data, but this Report is the first to provide a comprehensive and unified review of this topic. The major conclusions of this volume are: 1. Smoking cessation has major and immediate health benefits for men and women of all ages. Benefits apply to persons with and without smoking-related disease. 2. Former smokers live longer than continuing smokers. For example, persons who quit smoking before age 50 have one-half the risk of dying in the next 15 years compared with continuing smokers. 3. Smoking cessation decreases the risk of lung cancer, other cancers, heart attack, stroke, and chronic lung disease. 4. Women who stop smoking before pregnancy or during the first 3 to 4 months of pregnancy reduce their risk of having a low birthweight baby to that of women who never smoked. 5. The health benefits of smoking cessation far exceed any risks from the average 5-pound (2.3-kg) weight gain or any adverse psychological effects that may follow quitting. With the long-standing evidence that smoking is extremely harmful to health and the mounting evidence that smoking cessation confers majorr health benefits, we remain faced with the task of developing effective strategies to curtail the use of tobacco. Two broad categories of intervention are available: prevention of smoking initiation among youth and smoking cessation. Resources for tobacco control are limited, and policymakers must decide how best to allocate those resources to smoking prevention and cessation. The goal of public health is to intervene as early as possible to prevent disease, disability, and premature death. From that standpoint, prevention of smoking initiation i TIMN 438385

Public opinion polls tell us that most smokers want to quit. This Report provides smokers with new and more powerful motivation to give up this self-destructive behavior. Antonia C. Novello, M.D., M.P.H. Surgeon General xii TIMN 438395

should be a major priority. More than 3,000 teenagers become regular smokers each day in the United States. Because of the strength of nicotine addiction, some have argued that public health efforts should focus on smoking prevention rather than smoking cessation. However, this need not be an "either-or" situation. Public health practitioners have categorized interventions into primary, secondary, and tertiary prevention. Primary prevention generally refers to the elimination of risk factors for disease in asymptomatic persons. Secondary prevention is defined as the early detection and treatment of disease, and is practiced using tools such as Pap smears and blood pressure screening. Tertiary prevention consists of measures to reduce impairment, disability, and suffering in people with existing disease. Smoking cessation falls under the category of primary prevention as does the prevention of smoking initiation. Smoking cessation meets the definition of primary prevention by reducing the risk of morbidity and premature mortality in asymptomatic people. In addition, parents who quit smoking reduce or eliminate the risk of passive- smoking-related disease among their children and reduce the probability that their children will become smokers. Thus, there should be no debate about the need for smoking prevention versus cessation-both are important. Public awareness of the health effects of smoking has increased substantial ly through the years. Nevertheless, important gaps in public knowledge still exist. Some smokers may have failed to quit because of a lack of appreciation of the health hazards of smoking and the benefits of quitting. In the 1987 National Health Interview Survey of Cancer Epidemiology and Control, respondents were asked whether smoking increases the risk of various diseases (lung cancer, cancer of the mouth and throat, heart disease, emphysema, and chronic bronchitis) and whether smoking cessation reduces the risk. Thirty to forty percent of smokers either did not believe that smoking increases these risks or did not believe that cessation reduces these risks. These proportions correspond to 15 to 20 million smokers in the United States. Clearly, our efforts to educate the public on the health hazards of smoking and the benefits of quitting are not yet complete. As we continue and intensify our efforts to inform the public of these findings, we must make available smoking cessation programs and services to those who need them. Although 90 percent of former smokers quit without using smoking cessation programs, counseling, or nicotine gum, smokers who do need this assistance should have it available. We endorse the view expressed in the Preface to the 1988 Surgeon General's Report that treatment of nicotine addiction should be considered at least as favorably by third-party payors as treatment of alcoholism and illicit drug addiction. Good smoking cessation treatments can achieve abstinence rates of 20 to 40 percent at 1-year followup. Those success rates, combined with the enormous health benefits of smoking cessation, would likely make payment for some smoking cessation treatments cost- beneficial. For example, research by the Centers for Disease Control suggests that a smoking cessation program offered to all pregnant smokers could save $5 for every dollar spent by preventing low birthweiQht-associated neonatal intensive care and long-term care. ~ ii TIMN 438386

CHAPTER 1 INTRODUCTION, OVERVIEW, AND CONCLUSIONS TIMN 438416

ACKNOWLEDGMENTS This 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 Editor was Susan A. Hawk, Ed.M., M.S. The scientific editors of the Report were: Jonathan M. Samet, M.D. (Senior Scientific Editor), Professor of Medicine and Chief, Pulmonary Division, Department of Medicine and the New Mexico Tumor Registry, Cancer Center, University of New Mexico, Albuquerque, New Mexico Ronald M. Davis, M.D., Director, Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion (CCDPHP), Centers for Disease Control (CDC), Rockville, Maryland Neil E. Grunberg, Ph.D., Professor, Department of Medical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland Judith K. Ockene, Ph.D., Professor of Medicine, and Director, Division of Preventive and Behavibral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts Diana B. Petitti, M.D., M.P.H., Associate Professor, Department of Family and Com- munity Medicine, University of California at San Francisco, School of Medicine, San Francisco, California Walter C. Willett, M.D., Dr.P.H., Professor of Epidemiology and Nutrition, Harvard School of Public Health, and The Channing Laboratory, Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Mas- sachusetts The following individuals prepared draft chapters or portions of the Report: Robert Anda, M.D., Epidemiologist, Office of Surveillance and Analysis, CCDPHP, CDC, Atlanta, Georgia John Baron, M.D., Associate Professor of Medicine, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire Tim Byers, M.D., M.P.H., Chief, Epidemiology Branch, Division of Nutrition, CCDPHP, CDC, Atlanta, Georgia Arden G. Christen, D.D.S., M.S.D., M.A., Chairman, Professor, Department of Preven- tive and Community Dentistry, Indiana University School of Dentistry, Indianapolis, Indiana Graham Colditz, Dr.P.H., Assistant Professor of Medicine, Harvard School of Public Health, and the Channing Laboratory, Department of Medicine, Harvard Medical School and_Brigham and Women's Hospital, Boston, Massachusetts TIMN 438396 X"'

22 times higher among male smokers and 12 times higher among female smokers compared with people who have never smoked.The risk of lung cancer declines steadily in people who quit smoking; after 10 years of abstinence, the risk of lung cancer is about 30 to 50 percent of the risk for continuing smokers. Smoking cessation also reduces the risk of cancers of the larynx, oral cavity, esophagus, pancreas, and urinary bladder. Coronary heart disease (CHD) is the leading cause of death in the United States. Smokers have about twice the risk of dying from CHD compared with lifetime nonsmokers. This excess risk is reduced by about half among ex-smokers after only 1 year of smoking abstinence and declines gradually thereafter. After 15 years of abstinence the risk of CHD is similar to that of persons who have never smoked. Compared with lifetime nonsmokers, smokers have about twice the risk of dying from stroke, the third leading cause of death in the United States. After quitting smoking, the risk of stroke returns to the level of people who have never smoked; in some studies this reduction in risk has occurred within 5 years, but in others as long as 15 years of abstinence were required. Cigarette smoking is the major cause of chronic obstructive pulmonary disease (COPD), the fifth leading cause of death in the United States. Smoking increases the risk of COPD by accelerating the a~e-related decline in lung function. With sustained abstinence from smoking, the rate of decline in lung function among former smokers returns to that of never smokers, thus reducing the risk of developing COPD. Influenza and pneumonia represent the sixth leading cause of death in the United States. Cigarette smoking increases the risk of respiratory infections such as influenza, pneumonia, and bronchitis, and smoking cessation reduces the risk. Cigarette smoking is a major cause of peripheral artery occlusive disease. This condition causes substantial mortality and morbidity; complications may include inter- mittent claudication. tissue ischemia and gangrene, and ultimately, loss of limb. Smoking cessation substantially reduces the risk of peripheral artery occlusive disease compared with continued smoking. The mortality rate from abdominal aortic aneurysm is two to five times higher in current smokers than in never smokers. Former smokers have half the excess risk of dying from this condition relative to current smokers. About 20 million Americans currently have, or have had, an ulcer of the stomach or duodenum. Smokers have an increased risk of developing gastric or duodenal ulcers, and this increased risk is reduced by quitting smoking. Benefits at All Ages According to a 1989'Gallup survey, the proportion of smokers who say they would like to give up smoking is lower for smokers aged 50 and older (57 percent) than for smokers aged 18-29 (68 percent) and 30-49 (67 percent). Older smokers may be less motivated to quit smoking because the highly motivated may have quit already at younger ages, leaving a relatively "hard-core" group of older smokers. But many long-term smokers may lack motivation to quit for other reasons. Some may believe they are no longer at risk of smoking-related diseases because they have already survived smoking for many years. Others may believe that any damage that may have vi TIMN 438389

TABLE OF CONTENTS Foreword ........................................................... i Preface ............................................................. v Acknowledgments .................................................. xiii List of Tables ...................................................... xxv List of Figures ..................................................... xxxi 1. Introduction, Overview, and Conclusions ............................. 1 2. Assessing Smoking Cessation and Its Health Consequences .............. 17 3. Smoking Cessation and Overall Mortality and Morbidity ................ 71 4. Smoking Cessation and Respiratory Cancers ......................... 103 5. Smoking Cessation and Nonrespiratory Cancers ...................... 143 6. Smoking Cessation and Cardiovascular Disease ...................... 187 7. Smoking Cessation and Nonmalignant Respiratory Diseases ............ 275 8. Smoking Cessation and Reproduction .............................. 367 9. Smoking, Smoking Cessation, and Other Nonmalignant Diseases ........ 425 10. Smoking Cessation and Body Weight Change ........................ 469 11. Psychological and Behavioral Consequences and Correlates of Smoking Cessation ............................................. 517 Volume Appendix. National Trends in Smoking Cessation ................ 579 Glossary .......................................................... 617 Index............................................................. 619 xxui TIMN 438406

Previous Surgeon General's reports, in particular the landmark 1964 Report of the Surgeon General's Advisory Committee on Smoking and Health and the 1982 Surgeon. General's Report on smoking and cancer, examined these associations with respect to the epidemiologic criteria for causality. These criteria include the consistency, strength, specificity, coherence, and temporal relationship of the association. Based on these criteria, previous reports have recognized a causal association between smoking and cancers of the lung, larynx, esophagus, and oral cavity; heart disease; stroke; peripheral artery occlusive disease; chronic obstructive pulmonary disease; and intrauterine growth retardation. This Surgeon General's Report is the first to conclude that the evidence is now sufficient to identify cigarette smoking as a cause of cancer of the urinary bladder; the 1982 Report concluded that cigarette smoking is a contributing factor in the development of bladder cancer. The causal nature of most of these associations was well established lona before publication of this Report. Nevertheless, it is worth noting that the findings of this Report add even more weight to the evidence that these associations are causal. The criterion of coherence requires that descriptive epidemiologic findings on disease occurrence correlate with measures of exposure to the suspected agent. Coherence would predict that the increased risk of disease associated with an exposure would diminish or disappear after cessation of exposure. As this Report shows in great detail. the risks of most smoking-related diseases decrease after cessation and with increasing duration of abstinence. Evidence or} the risk of disease after smoking cessation is especially important for the understanding of smoking-and-disease associations of unclear causality. For ex- ample, cigarette smoking is associated with cancer of the uterine cervix, but this association is potentially confounded by unidentified factors (in particular by a sexually transmitted etiologic agent). The evidence reviewed in this Report indicates that former smokers experience a lower risk of cervical cancer than current smokers, even after adjusting for the social correlates of smoking and risk of sexually acquired infections. This diminution of risk after smoking cessation supports the hypothesis that smoking is a contributing cause of cervical cancer. Conclusion The Comprehensive Smoking Education Act of 1984 (Public Law 98-474) requires the rotation of four health warnings on cigarette packages and advertisements. One of those warnings reads, "SURGEON GENERAL'S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health." The evidence reviewed in this Report confirms and expands that advice. The health benefits of quitting smoking are immediate and substantial. They far exceed any risks from the average 5-pound weight gain or any adverse psychological effects that may follow quitting. The benefits extend to men and women, to the young and the old, to those who are sick and to those who are well. Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives. xi TIMN 438394