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Smoking cessation programs and messages should emphasize that weight gain after quitting is small on average. Not only is the average postcessation weight gain small, but the risk of large weight gain after quitting is extremely low. Less than 4 percent of those who quit smoking gain more than 20 pounds. Nevertheless, special advice and assistance should be available to the rare person who does gain considerable weight after quitting. For these individuals, the health benefits of cessation still occur, and weight control programs rather than smoking relapse should be implemented. Increases in food intake and decreases in resting energy expenditure are largely responsible for postcessation weight gain. Thus, dietary advice and exercise should be helpful in preventing or reducing postcessation weight gain. Unfortunately, minor weight control modifications to smoking cessation programs do not generally yield beneficial effects in terms of reducing weight gain or increasing cessation rates. A few studies have investigated pharmacologic approaches to postcessation weight control; preliminary results are encouraging but more research is needed. High priority should be given to the development and evaluation of effective weight control programs that can be targeted in a cost-effective manner to those at greatest need of assistance. Psychological and Behavioral Consequences of Smoking Cessation Nicotine withdrawal symptoms include anxiety, irritability, frustration, anger, dif- ficulty concentrating, increased appetite. and urges to smoke. With the possible exception of urges to smoke and increased appetite, these effects soon disappear. Nicotine withdrawal peaks in the first I to 2 days following cessation and subsides rapidly during the following weeks. With long-term abstinence, former smokers are likely to enjoy favorable psychological changes such as enhanced self-esteem and increased sense of self-control. Although most nicotine withdrawal symptoms are short-lived, they often exert a strong influence on smokers' ability to quit and maintain abstinence. Nicotine withdrawal may discourage many smokers from trying to quit and may precipitate relapse among those who have recently quit. In the 1986 Adult Use of Tobacco Survey, 39 percent of current smokers reported that irritability was a "very important" or "somewhat important" reason why they resumed smoking after a previous quit attempt. Smokers and ex-smokers should be counseled that adverse psychological effects of smoking subside rapidly over time. Smoking cessation materials and programs, nicotine replacement, exercise, stress management, and dietary counseling can help smokers cope with these symptoms until they abate, after which favorable psychologi- cal changes are likely to occur. Support for a Causal Association Between Smoking and Disease Tens of thousands of studies have documented the associations between cigarette smoking and a large number of serious diseases. It is safe to say that smoking represents the most extensively documented cause of disease ever investigated in the history of biomedical research. x TIMN 438393

Carlo C. DiClemente, Ph.D., Associate Professor, Department of Psychology, Univer- sity of Houston, Houston, Texas Douglas W. Dockery, Sc.D., Associate Professor, Department of Environmental Health, Environmental Epidemiology Program, Harvard School of Public Health, Boston, Massachusetts Gary A. Giovino, Ph.D., Acting Chief, Epidemiology Branch, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Deborah Grady, M.D.; Assistant Professor, Departments of Epidemiology and Medicine, University of California at San Francisco, School of Medicine, San Francisco, California Neil E. Grunberg, Ph.D., Professor, Department of Medical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland John R. Hughes, M.D., Associate Professor, Human Behavioral Pharmacology Laboratory, Departments of Psychiatry, Psychology, and Family Practice, University of Vermont, Burlington, Vermont Robert W. Jeffery, Ph.D., Professor, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota LTC James W. Kikendall, M.D., Assistant Chief, Gastroenterology Section, Walter Reed Army Medical Center, Washington, D.C. Robert Klesges, Ph.D., Associate Professor, Department of Psychology, Memphis State University, Memphis, Tennessee Lynn Kozlowski, Ph.D., Head, Behavioral Tobacco Research, Socio-behavioral Re- search Department, Addiction Research Foundation, Toronto, Ontario, Canada Stephen Marcus, Ph.D., Epidemiologist, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland James L. McDonald, Jr., Ph.D., Assistant Chaitman. Professor, Department of Preven- tive and Community Dentistry, Indiana University School of Dentistry, Indianapolis, Indiana Sherry L. Mills, M.D.. M.P.H., Medical Officer, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Judith K. Ockene, Ph.D., Professor of Medicine, and Director. Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts Carole Tracy Orleans, Ph.D., Director, Smoking Cessation Services, Fox Chase Cancer Center, Cheltenham, Pennsylvania 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 John P. Pierce, Ph.D., Associate Professor, Director, Population Studies and Cancer Prevention, Tobacco Control Project. University of California, San Diego Cancer Center, San Diego, California Paul R. Pomrehn, Ph.D., M.S., Associate Professor, Department of Preventive Medicine and Environmental Health. University of Iowa College of Medicine, Iowa City, Iowa James O. Prochaska, Ph.D., Professor, Director, Cancer Prevention Research Unit, Department of Psychology, University of Rhode Island, Kingston, Rhode Island xiv TIMN 438397

smoking. Smoking cessation reduces the risk of respiratory infections such as pneumonia, which are often the immediate causes of death in patients with an under- lying chronic disease. The important role of health care providers in counseling patients to quit smoking is well recognized. Health care providers should give smoking cessation advice and assistance to all patients who smoke, including those with existing illness. Benefits for the Fetus Maternal smoking is associated with several complications of pregnancy including abruptio placentae, placenta previa, bleeding during pregnancy, premature and prolonged rupture of the membranes, and preterm delivery. Maternal smoking retards fetal growth, causes an average reduction in birthweight of 200 g, and doubles the risk of having a low birthweight baby. Studies have shown a 25- to 50-percent higher rate of fetal and infant deaths among women who smoke during pregnancy compared with those who do not. Women who stop smoking before becoming pregnant have infants of the same birthweight as those born to women who have never smoked. The same benefit accrues to women who quit smoking in the first 3 to 4 months of pregnancy and who remain abstinent throughout the remainder of pregnancy. Women who quit smoking at later stages of pregnancy, up to the 30th week of gestation, have infants with higher birthweight than do women who smoke throughout pregnancy. Smoking is probably the most important modifiable cause of poorpregnancy outcome among women in the United States. Recent estimates suggest that the elimination of smoking during pregnancy could prevent about 5 percent of perinatal deaths, about 20 percent of low birthweight births, and about 8 percent of preterm deliveries in the United States. In groups with a high prevalence of smoking (e.g., women who have not completed high school), the elimination of smoking during pregnancy could prevent about 10'percent of perinatal deaths. about 35 percent of low birthweight births, and about 15 percent of preterm deliveries. The prevalence of smoking during pregnancy has declined over time but remains unacceptably high. Approximately 30 percent of U.S. women who are cigarette smokers quit after recognition of pregnancy, and others quit later in pregnancy. However, about 25 percent of pregnant women in the United States smoke throughout pregnancy. A shocking statistic is that half of pregnant women who have not completed high school smoke throughout pregnancy. Many women who do not quit smoking during pregnancy reduce their daily cigarette consumption; however, reduced con- sumption without quitting may have little or no benefit for birthweight. Of the women who quit smoking during pregnancy. 70 percent resume smoking within I year of delivery. Initiatives have been launched in the public and private sectors to reduce smoking during pregnancy. These programs should be expanded, and less educated pregnant women should be a special target of these efforts. Strategies need to be developed to address the problem of relapse after delivery. viii TIMN 438391

LIST OF TABLES Chapter 2 Table 1. Measures of false reports of not smoking from studies using nicotine and cotinine as a marker .................................... 38 Table 2. Measures of false reports from studies using CO as a marker ......... 41 Table 3. Examples of potential methodologic problems in investigating the health consequences of smoking cessation .......................... 47 Chapter 3 Table 1. Summary of longitudinal studies of overall mortality ratios relative to never smokers among male current and former smokers according to duration of abstinence (when reported) ..................... 76 Table 2. Overall mortality ratios among current and former smokers, relative to never smokers, by sex and duration of abstinence at date of enrol lment, ACS CPS-II ........................................... 78 Table 3. Estimated probability of dying in the next 16.5-year interval for quitting at various ages compared with never smoking and continuing to smoke, by amount smoked and sex ................................ 83 Table 4. Summary of overall mortality ratios in intervention studies in which smoking cessation was a component ...................... . ..... 84 Table 5. Summary of studies of medical care utilization among smokers andformersmokers .............................................. 88 Table 6. Relation of smoking cessation to various measures of general health status ...................................................90 Table 7. Age- and sex-specific mortality rates among never smokers, continuing smokers, and former smokers by amount smoked and duration of abstinence at time of enrollment for subjects in ACS CPS-II study who did not have a history of cancer, heart disease, or stroke and were not sick at enrollment ................................ 95 Table 8. Estimated probability of dying in the next 16.5-year interval (95% CI) for quitting at various ages compared with never smoking and continuing to smoke, by amount smoked and sex .................... 97 TIMN 438407 Xxv .

Chapter 4 Table 1. Histologic changes (%) in bronchial epithelium by smoking status .........................................................109 Table 2. Relative risks of lung cancer among never, former, and current smokers in selected epidemiologic studies ............................ 111 Table 3. Lung cancer mortality ratios among never, current, and. former smokers by number of years since stopped smoking (relative to never smokers), prospective studies ...................................... 112 Table 4. Relative risks of lung cancer among former smokers, by number of years since stopped smoking, and current smokers, from selected case-control studies ...................................... 115 Table 5. Relative risks of lung cancer among never, current, and former smokers, by number of years since stopping smoking and histologic type .......................................................... 119 Table 6. Relative risks of lung cancer among never, former, and current smokers by types of tobacco products smoked ........................ 120 Table 7. Standard mortality ratios of lung cancer among former smokers in ACS CPS-II (relative to never smokers) by years of smoking abstinence, daily cigarette consumption at time of cessation, and history of chronic disease ......................................... 130 Table 8. Histologic changes in laryngeal epithelium by smoking status ...... 132 Table 9. Relative risks of laryngeal cancer by smoking status . .............. 133 Chapter 5 Table 1. Studies of oral cancer and smoking cessation ................... 148 Table 2. Studies of esophageal cancer that have examined the effect of smoking cessation ............................................... 153 Table 3. Studies of cancer of the pancreas and smoking cessation .......... 156 Table 4. Studies of bladder cancer and smoking cessation ................ 160 Table 5. Bladder cancer risk according to smoking dose, duration of smoking, and smoking status ...................................... ~ 165 Table 6. Studies of cervical cancer and smoking cessation ................ 167 Table 7. Studies of breast cancer and smoking cessation .................. 170 Table 8. Studies of cancer at selected sites that have examined the effect of smoking cessation ............................................. 173 xxvi TI~~ 438408

Chapter 8 Figure 1. Perinatal, neonatal, and fetal mortality rates by birthweight in singleton white males, 1980 ....................................... 380 Chapter 11 Figure 1. Performance on a meter (i.e., visual) vigilance task. Performance on the continuous clock task, a visual vigilance task ........ 527 Figure 2. Self-reported withdrawal discomfort among abstinent smokers .... 531 Figure 3. Drinking relative to smoking status for men, 1983 NHIS ......... 558 Figure 4. Drinking relative to smoking status for women, 1983 NHIS ....... 559 Appendix Figure 1. Trends in the quit ratio, United States, 1965-87, by gender ........ 590 Figure 2. Trends in the quit ratio, United States, 1965-87, by race .......... 591 Figure 3. Flow chart of quitting history, attempts lasting longer than 1 year, NHEFS .................................................. 597 Figure 4. Estimated duration of abstinence on first 1-year or longer quit attempt, product-limit method, N=3,363 ............................. 598 Figure 5. Percentage of ever smokers who never tried to quit, by education, United States, 1974-87 .................................. 601 Figure 6. Percentage of persons smoking at 12 months prior to the survey interview who quit for at least I day during those 12 months, United States, 1978-80, 1987, by education .......................... 602 Figure 7. Percentage of ever smokers who had been abstinent for less than 1 year, United States, 1966-87, by education ..................... 603 Figure 8. PercentaQe of ever smokers who had been abstinent for 1-4 years, United States, 1966-87, by education .......................... 604 Figure 9. Percentage of ever smokers who had been abstinent for 5 years or more, United States, 1966-87, by education ........................ 605 ~jM-S 438415 xXXiii

Table 6: Summary of data from 1987 BRFSS, behaviors of former smokers aged 18 and older by duration of abstinence ................... 552 Table 7. Percent distribution of persons aged 18 and older by tobacco product and use status, according to gender and cigarette smoking status, United States, 1987 ........................................ 557 Table 8. Physician visits and medical tests within the past year among AARP members aged 50 and older, by smoking status .................. 563 Volume Appendix Table 1. Quit ratio in selected States, by age group and gender-BRFSS, 1988 ........................................................... 586 Table 2. Cigarette smoking continuum by year, percentage of ever cigarette smokers, by NHISs, United States, 1978-87, adults aged 20 and older ...................................................... 589 Table 3. Trends in quit ratio (%) (percentage of ever cigarette smokers who are former cigarette smokers), by age and by education. NHISs, United States, 1965-87, adults aged 20 and older ...................... 592 Table 4. Effect of adjusting for use of other tobacco products on quit ratio (percentage of ever cigarette smokers who are former cigarette smokers), 1987, NHIS, United States ................... ............. 594 Table 5. Selected measures of quitting activity (%), NHISs, United States, adults aged 20 and older .................................... 600 Table 6. Percentage of those intending to smoke in 5 years, by gender, AUTSs, United States, 1964-86, current smokers aged 21 and older ....... 609 Table 7. Percentage who report having ever received advice to quit from a doctor, by smoking status and gender, United States. 1964-87, adults aged 21 and older ...............................................610 xxx Tlldil~ 438412

William A. Robinson, M.D., M.P.H., Director, Office of Minority Health. Department of Health and Human Services, Washington, D.C. William L. Roper, M.D., M.P.H., Director, CDC, Atlanta, Georgia Richard B. Rothenberg, M.D., Assistant Director for Science, CCDPHP, CDC. Atlanta, Georgia Thomas C. Schelling, Ph.D., Director, Institute for the Study of Smoking Behavior and Policy, Lucius N. Littauer Professor of Political Economy, Harvard University, Cambridge, Massachusetts Marc B. Schenker, M.D., M.P.H., Associate Professor and Division Chief, Occupation- al and Environmental Medicine. University of California, Davis, Davis, California David Schottenfeld, M.D., Professor and Chairman, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan Kathleen L. Schroeder, D.D.S., M.Sc., Assistant Professor, Section of Oral Biology, The Ohio State University College of Dentistry, Columbus, Ohio Mary J. Sexton, Ph.D., M.P.H., Professor, Department of Epidemiology and Preventive Medicine. University of Maryland School of Medicine, Baltimore, Maryland Saul Shiffman, Ph.D., Associate Professor, Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania Donald Shopland, Smokins. Tobacco, and Cancer Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Amnon Sonnenberg, M.D., Associate Professor, Gastroenterology Section, Medical College of Wisconsin, Veterans Administration Medical Center, Milwaukee. Wis- consin Frank E. Speizer, M.D., Professor of Medicine, Harvard Medical School, Professor of Environmental Epidemiology, Harvard School of Public Health, Co-Director, The Channing Laboratory, Department of Medicine, BriQham and Women's Hospital, Boston, Massachusetts ~ Jesse Steinfeld, M.D., San Diego, California Steven D. Steliman, Ph.D., Assistant Commissioner, New York City Department of Health, New York, New York Ira B. Tager, M.D., M.P.H., Associate Professor of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, Veterans Administration Medi- cal Center, San Francisco, San Francisco, California Kenneth Warner, Ph.D., Senior Fellow, Institute of Gerontology, University of Michigan, Ann Arbor, Michigan Jonathan S. Weiss, M.D., Assistant Professor of Dermatolosy, Section of Dermatology, Emory Clinic, Atlanta, Georgia ~ Noel S. Weiss, M.D., Dr.P.H., Professor and Chairman, Department of Epidemiology, University of Washington, Seattle, Washington y Gail R. Wilensky, Ph.D., Administrator, Health Care Financing Administration. Washington, DC ~ Deborah Winn, Ph.D., Deputy Director, Division of Health Interview Statistics, Na- tional Center for Health Statistics, CDC, Hyattsville, Maryland Philip A. Wolf, M.D., Professor of Neurology, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts Ernst L. Wynder, M.D., President, American Health Foundation, New York, New York TIMN 438402 xiX

U Sharon K. Faupel, Staff Assistant, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Leanna Fernando, Administrative Assistant, New Mexico Tumor Registry, University of New Mexico, Albuquerque, New Mexico David Fry, Editor, The Circle, Inc., McLean, Virginia Lynn Funkhauser, Word Processing Specialist, The Circle, Inc., McLean, Virginia Amy Garson, Student Intern, Office on Smoking and Health, CCDPHP, CDC, Rock- ville, Maryland Mary Graber, Secretary, University of California at San Francisco, School of Medicine, Department of Family and Community Medicine, San Francisco, California Gwen Harvey, Program Analyst, CCDPHP, CDC, Atlanta, Georgia Patricia Healy, Technical Information Specialist, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Phyllis E. Hechtman. Editorial Assistant, The Circle, Inc., McLean, Virginia Timothy K. Hensley, Technical Publications Writer-Editor, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Julian Hudson, Courier, The Circle, Inc., McLean, Virainia Beth Jacobsen, Student Intern, Office on Smoking and Health, CCDPHP. CDC, Rockville, Maryland Renee Kolbe, Program Specialist, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Matt Kreuter, Public Information Specialist, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Peggy Lytton. Editor, The Circle, Inc.. McLean, Virginia Diana Lord, Research Psychologist, Department of Medical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland Daniel F. McLaughlin, Editor, The Circle, Inc., McLean, Virginia Jackie L. Meador, Desktop Publishing/Word Processing Specialist, The Circle. Inc., McLean, Virginia Elaine Medoff-IVicGovern, Medical Secretary, Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts Nancy A. Miltenberger, M.A., Production Editor, The Circle, Inc., McLean. Virginia Rebecca Mosher, Staff Assistant, New Mexico Tumor Registry, University of New Mexico, Albuquefque, New Mexico Millie R. Naquin. Research Assistant, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Thomas E. Novotny, M.D., Chief, Program Services Activity, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Cathie M. O'Donnell, Project Director, The Circle, Inc., McLean, Virginia Christine Pappas, Editorial Research Assistant, The Channing Laboratory, Harvard School of Public Health, Boston, Massachusetts Stacey M. Parcover, Secretary, Office on Smoking and Health, CCDPHP, CDC, Rockville, Maryland Lida Peterson, Computer Systems Manager, The Circle, Inc., McLean, Virginia TIMN 438404 xxi

LIST OF FIGURES Chapter 2 Figure 1. Cyclical model of the stages of change ......................... 23 Figure 2. Hypothetical examples of disease incidence rates for current, fotmer, and never smokers, by age .................................... 55 Chapter 3 Figure 1. Compared with never smokers, relative risk of mortality in current and former smokers aged 50-54, 60-64, and 70-74 at enrollment, by amount smoked and duration of abstinence ................ 81 Figure 2. Estimated probability of dying in the next 16.5-yr interval for quitting at ages 55-59 compared with never smoking and continuing to smoke, by sex ................................................... 98 Chapter 4 Figure 1. Risk of lung cancer by number of cigarettes smoked per day before quitting, number of years of abstinence, sex, and histologic types ... 121 Figure 2. Relative risk of lung cancer among ex-smokers compared with continuing smokers as a function of time since stopped smoking, estimated from locristic regression model, pattern adjusted for smoking duration compared with pattern unadjusted for duration ................. .123 Figure 3. Incidence of bronchial carcinoma among continuing cigarette smokers in relation to age and duration of smokine and among never smokers in relation to age, double logarithmic scale .................... 127 Chapter 6 Figure 1. Hypothetical effects of smoking cessation on risk of CHD if mechanisms' are predominantly rapidly reversible ...................... 198 Figure 2. Estimated relative risk of MI after quitting smoking among men under age 55, adjusted for age ................................. 204 Figure 3. Mortality ratios due to coronary artery diseases; rates for men who have stopped smoking are compared with those for men who never smoked and those for men still smoking in 1952 .................. 214 Figure 4. Mortality ratios for all cardiovascular diseases and CHD, by daily cigarette consumption, US Veterans Study, 1954-69 ............... 219 Figure 5. Mortality ratio for current and former cigarette smokers by years of smoking cessation, US Veterans Study, 1954-69 ................ 220 TIMN 438413 Xxxi