ae wale Health Consequences of SMOKING 1977-1978 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Office of the Assistant Secretary for Health Office on Smoking and Health The Health Consequences of SMOKING 1977-1978 DHEW Publication No. (PHS) 79-50065 US. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service e of the Assistant Secretary for Hea Oftice on Smoking and Health Rockville, Md. Maryland 20857 Offic Ith The Honorable Thomas P. O’Neill Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: As required by Section 8(a) of the Public Health Cigarette Smoking Act of 1969, I am submitting the 1977-1978 report on the health consequences of smoking. The report includes the “Bibliography on Smoking and Health—1976,” the “Bibliography on Smoking and Health-1977,” and “The Health Consequences of Smoking, 1977- 1978.”* The report bears a 2-year designation in order to return the series to an annual timetable which was altered because of the time required for the clearance processing of the 1976 report. The Bib- liographies are prepared annually and routinely to reflect the new acquisitions to the smoking and health data base which operates at a cost of $200,000.00 per year; the health consequences of smoking report, which is a review of this new current information and pre- pared specifically for Congress, this year cost $9,800.00. “The Health Consequences of Smoking, 1977-1978” includes re- cently published data from three classic prospective studies of the mortality resulting from cigarette smoking. These studies, involving almost one and a half million persons, continue to document excess mortality among smokers as compared to nonsmokers. This part of the report also includes data on the established risks of low birth weight and increased perinatal mortality for offspring of women who smoke during pregnancy. In addition, the new evi- dence is reviewed that shows not only a high rate of heart attacks among women who smoke cigarettes, but that this effect is particu- larly critical in women who use oral contraceptives. The data in this report indicate that former smokers show lower death rates than continuing smokers and within 10 to 15 years after quitting come close to the low rates of those who never smoked. One study supports previous evidence that there is a partial solution to the health problem in the use of cigarettes with lower emissions of ‘‘tar” and nicotine. As a result of public demand and a responsive industry, there has been over recent years a continuing decline in the emissions of “tar” and nicotine in cigarettes in use. The data in this report and in previous annual reviews of the health consequences of smoking have established cigarette smoking as a habit responsible for an overwhelming level of premature death and disability in this country. To reduce this preventable and costly *The bibliographies have been published as DHEW Publication Number (CDC) 78-8309, January and February 1978. ii mortality and morbidity, this Department recently announced a new antismoking program. The program is one of public education, regulation, and research with special emphasis on children, teenagers, and young women, and on occupations where smoking increases risks from occupational exposure. In undertaking this program, I have invited the coopera- tion of the major broadcast networks, State and local school offi- cials, the major corporations of this Nation, State Governors and legislators, the Federal Trade Commission, the Federal Communi- cations Commission, the Civil Aeronautics Board, and others whose involvement and cooperation are crucial to the success of this pro- gram. In response to the evidence linking the combined use of oral contraceptives and cigarette smoking, the Food and Drug Admin- istration, Public Health Service, HEW, has recently required that a warning statement to that effect accompany oral contraceptives as they are distributed to those who use them. To provide leadership and to coordinate this program, an Office on Smoking and Health has been established in the Office of the Assistant Secretary for Health. As one of its first tasks, this Office will coordinate the pro- duction of a comprehensive document which reviews not only the biomedical but also the behavioral and control data about smoking and its effects on health. The report will be submitted to Congress . in January 1979. As the principal health officials of this government, the Surgeon General and | are committed to fulfilling our responsibilities to pro- vide information and direction to permit American citizens to make genuinely free choices about smoking and their own health. In this regard and as I am required by P.L. 91-222 to make such legislative recommendations that I deem appropriate based on the scientific data about the impact of smoking on health, I will submit within the year a legislative package which I hope will meet with your approval. With appropriate coordination of legislative action and program, we can solve this difficult and important public health problem. Sincerely, i , bay mt Joseph A. Califano, Jr. Secretary Enclosures Identical letter sent to The Honorable Walter F. Mondale ‘Preface This tenth report to the Congress on the health consequences of smoking discusses the special problems incurred by women who smoke and presents recently published overall mortality data on smoking. , Smoking was first recognized as a health problem in the 1930's, when a sharp increase was noted in lung cancer rates for men. No similar increase was noted for women at that time for several rea- sons. First, as a group, women did not start smoking when men did, since such behavior was socially unacceptable for women at that time. Consequently, until the last decade, there were insuffi- cient numbers of women who had smoked for a long enough period of time to provide the size population necessary for meaningful research. In recent years, however, the same health risks to men as a re- sult of smoking have been documented for women who smoke. These include cardiovascular disease, lung cancer, cancer of other specific sites, bronchitis, and emphysema. These diseases occur among smokers at rates far greater than those of nonsmokers. Ad- ditionally, women have been found to incur unique risks for them- selves and for their offspring. For example, women over 30 years of age who smoke and use oral contraceptives have substantially higher risks of myocardial infarction. Moreover, the offspring of women who smoke during pregnancy face greater risks of perinatal mortal- ity and low birth weight. Further understanding of the mechanisms involved in these health consequences continues to evolve. Three large prospective epidemiologic studies demonstrate that overall mortality rates for cigarette smokers are approximately 70 percent higher than those for nonsmokers. These studies also docu- ment a decrease in overall mortality rates for those who quit smok- ing, provided they were not ill af the time of cessation. There is about a 15 percent reduction in overall mortality risk for smokers of low “tar” and nicotine cigarettes (less than 17.6 mg. “tar” and less than 1.2 mg. nicotine) compared to those who smoke high “tar” and nicotine cigarettes (25.8-35.7 mg. “tar” and 2.0-2.7 mg. nicotine). Several publications have become available since the last report to Congress which review the social, behavioral, legislative, and health issues related to smoking. A recently published paper by Daniel Horn, Ph.D., as part of his work with the World Health Organization, discusses the major barriers to be overcome if further progress is to be made against the threat of smoking to health. A copy is included as Appendix A to this report. Two other publica- tions of note include the U.S. Public Health Service’s “Proceedings of the Third World Conference on Smoking and Health, 1975,” DHEW Publication No. (NIH) 77-1413, 1977, Volumes I and II, and the World Health Organization’s “Smoking and Its Effects on Health,” Technical Report Series No. 568, Switzerland, 1975. Table of Contents Page Preface .... ccc ce cee cee ce eee eet eect eee e eee iv Table of Contents .... 0... 00 eee cece cece eee e tenn eeees vi Preparation of the Report and Acknowledgments ........- xiii Chapter 1. Smoking-Related Health Problems Unique to Women ........- +e eee renee ceces xvii Introduction ........ 0. eee cee te eee ttre en ones i Effects of Smoking on the Outcome of Pregnancy ......... I Smoking and Birth Weight ........... eee e eee ee eees 1 Smoking and Perinatal Mortality ..........- se eeeeees 2 Long-Term Effects on Physical and Intellectual Development ........- eee e ee eeeees 8 Carbon Monoxide and Carboxyhemoglobin Levels in Maternal and Fetal Circulation and the Possible Mechanisms of Smoking Effects on Pregnancy ...........- 9 Smoking and Its Effects on Cardiovascular Disease ~ Among Women Taking Oral Contraceptives .........--++> 13 Effects of Cigarette Smoking on Lactation ...........-+-+ 15 What Women Know About Smoking and Pregnancy ....... 15 Summary of Smoking-Related Health Problems Unique to Women .......... 6+ e eee e ere eeeee 17 References ........ cece cece reece reece cece ences AB Chapter 2. Smoking and Overall Mortality......--.-+--+- 21 Introduction ........ 0.2 c cee e etter rere eens 22 Measuring Mortality .......0. 2c eee cere rece eee eerere 24 Mortality Ratios ....... cece eee een eee e eee 24 Differences in Mortality Rates ......-- see eeeeeeeees 24 Excess Deaths ........ 0c cece ence eee teen erences 24 Life Expectancy ----+5 +77 Description of the Studies ..---esrrrccr 25 The American Cancer Society Study ..--ee errr 25 The U.S. Veterans Study .-eee eer 26 The British Doctors Study .-cee cece 26 Overall Mortality and Cigarette Smoking .-----:ec°9tt tt" 27 Number of Cigarettes Smoked .--- seer 27 Age Began Smoking ..---eecr 28 Inhalation Practice... eee e eee 29 uTar” and Nicotine ..--secrer reese eset 29 - mx-Smokers .eceeeececesseces sere eee eee 32 Pipe and Cigar Smoking ..-e reer ere 38 Summary of Smoking and Overall Mortality ..-+----° nee . 44 References ..ccrececeecec sees sees esse eee TS 45 Appendix ...eeceeecs ners sent ees eee 47 Index coceceeeeeceenee esse tees eee TS CHAPTER 1 List of Figures Figure 1.— Risks of selected pregnancy complications for smoking and nonsmoking mothers, by period of gestational age at delivery for A, abruptio placentae, B, placenta previa, C, premature rup- ture of membranes (PROM) ..-- eee 6 Figure 2.— Number of cigarettes normally smoked per day compared with COHb level at time of sampling in 93 pregnant women.© = mean and range of COHb levels for 129 nonsmokers ..---+-0677"" 10 Figure 3.— Table 1.— Table 2.— Table 3.— Table 4.— Table 5.— Figure 1.— Figure 2.— Oxyhemoglobin saturation curves of human maternal and fetal blood under control and steady-state conditions .....--+++errrrrerree 12 List of Tables Adjusted rates and F ratios for maternal smoking and other important factors affecting birth weight, gestation, placental complications, and perinatal mortality ....----+-+-+rrrrere? 4 Perinatal mortality and selected pregnancy complications, by maternal smoking levels ....-- 7 Stillbirths according to cause in relation to maternal smoking during pregnancy ...----+---+° 8 Estimated annual mortality rate per 100,000 women from myocardial infarction and throm- boembolism, by use of oral contraceptives, smoking habits, and age (in years) ...-e ee eeeee 14 Estimated relative risks of nonfatal myocardial infarction, by use of oral contraceptives and cigarette smoking ...-.--+-+ererrrecrertete 14 CHAPTER 2 List of Figures Annual probability of dying for current cigarette smokers, ex-smokers who quit less than 5 years ago, and never smokers, ages 55-64... eee cece eee reer e tee t eet 34 Annual probability of dying for current cigarette smokers, ex-smokers who quit 5-9 years ago, and never smokers, ages 55-64 cece cee cee ete net eee eee eee eee 35 Figure 3.— Figure 4.— Table 1.— Table 2.— Table 3.— Table 4.— Table 5.— Table 6.— Annual probability of dying for current cigarette smokers, ex-smokers who quit 10-14 years ago, and never smokers, ages Ce eee ee eee nee eeneegee 36 Annual probability of dying for current cigarette smokers, ex-smokers who quit more than 15 years ago, and ex-smokers, ae 37 List of Tables Age-adjusted mortality ratios for male cigarette smokers, by amount smoked, U.S. Veterans Study, 1954 cohort, 16- year follow-up ..--eerrrcrecreesss 27 Mortality ratios for cigarette smokers, by number of cigarettes smoked per day, British Doctors Study... eee cece e eerste 28 Mortality ratios for male cigarette smok- ers, by age and number of cigarettes smoked per day, U.S. Veterans Study, 1954 cohort, 16-year follow-Up ...-e seer errr? 28 Age-adjusted mortality ratios for male cigarette smokers, by age began smoking, US. Veterans Study, 1954 cohort, 16- year follow-up ..+--eeeerrcrreresset 29 Age-adjusted mortality ratios for male cigarette smokers, by number of cigar- ettes smoked per day and age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up .----+-ssrrrrerrr 29 Mortality ratios for cigarette smokers, by inhalation practice, British Doctors Study oo. cece cee c eres seers 29 Table 7.— Mortality ratios for all cigarette smokers in two time periods, by sex and “tar” and nicotine (T/N) content in cigarettes smoked .... Table 8.— Mortality ratios for smokers of low “tar” and nicotine (T/N) cigarettes and nonsmokers in two time periods, by SCX... 2... eee eee eee ees Table 9.— Mortality ratios for all cigarette smokers and nonsmokers in two time periods, by sex and “tar” and nicotine (T/N) content of cigarettes smoked ...... ccc cece cc rece eee e ner enees Table 10.— Mortality ratios for ex-smokers who quit smoking on doctor’s orders and for other reasons, by years since stopping, U.S. Veterans Study, 1954 cohort, 16-year follow-up ....... Table 11.— Mortality ratios for ex-smokers who quit smoking on doctor’s orders and for other reasons, by number of cigarettes smoked per day, U.S. Veterans Study, 1954 cohort, 16- year follow-up ....... 00. eee eee eee eters Table 12.— Mortality ratios for ex-smokers who quit smoking on doctor’s orders and for other reasons, by age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up ....... Table 13.— Mortality ratios for ex-smokers of cigarettes only, by years since stopping, number of cigarettes smoked per day, and age began smoking. U.S. Veterans Study 1954 cohort, 16-year follow-up . 02.2... cece eee ee ee ee eee Table 14.— Mortality ratios for ex-smokers compared to nonsmokers, by number of years since stop- ping and age, British Doctors Study .......... 30 Table 15.— Age-adjusted mortality ratios for pipe-only, cigar-only, and cigarette-only smokers, U.S. Veterans Study, 1954 cohort, 16-year follow-up ..eeeeece eerste Table 16.— Age-adjusted mortality ratios for current cigar smokers, by number of cigars smoked per day, U.S. Veterans Study, 1954 cohort, 16- year follow-up .---seercrrrs Table 17.— Age-adjusted mortality ratios for current cigar smokers, by age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up ..----- Table 18.— Age-adjusted mortality ratios for current cigar smokers, by number of cigars smoked per day and age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up ...- eer eerets Table 19.— Age-adjusted mortality ratios for current pipe smokers, by number of pipefuls smoked per day, U.S. Veterans Study, 1954 cohort, 16- year follow-up ..--errrcrr srt Table 20.— Age-adjusted mortality ratios for current pipe smokers, by age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up ..---- Table 21.— Age-adjusted mortality ratios for current pipe smokers, by number of pipefuls smoked per day and age began smoking, U.S. Veterans Study, 1954 cohort, 16-year follow-up ..---- Table 22.— Age-adjusted mortality ratios for current cigar smokers, by use of other types of tobacco, USS. Veterans Study, 1954 cohort, 16-year follow-UP weeeeecc rrr crt xi Table 23.— Age-adjusted mortality ratios for current pipe smokers, by use of other types of tobacco, U.S. Veterans Study, 1954 cohort, 16-year fOOW-UP . 0. cc ect cece cree erences 42 Table 24.— Age-adjusted mortality ratios for current cigar- ette smokers, by use of other types of tobacco, U.S. Veterans Study, 1954 cohort, 16-year follow-UP . 2... cece cece cece eee eeeeeee 42 Table 25.— Age-adjusted mortality ratios for all smokers, xii by type of tobacco used, British Doctors Study . . 43 Preparation of the Report and Acknowledgments PREVIOUS REPORTS Reviews of the scientific information linking smoking to health problems began in 1964 with the publication of Smoking and Health, Report of the Advisory Committee to the Surgeon General of the Public Health Service, subsequently referred to as the “Sur- geon General’s Report.” Thereafter, Public Law 89-92 was passed requiring supplemental reports to Congress on this subject, and the following three reports were published: 1. The Health Consequences of Smoking, A Public Health Service Review; 1967 4. The Health Consequences of Smoking, 1968 Supplement to the 1967 PHS Review. 3. The Health Consequences of Smoking, 1969 Supplement to the 1967 PHS Review. Public Law 91-22 amended the previous law in April 1970 and required a comprehensive review within 18 months, with annual reports to be submitted thereafter. The result of this review was The Health Consequences of Smoking, A Report of the Surgeon General; 1971. Since then, the following annual reports on the health effects of smoking have been published: 1. The Health Consequences of Smoking, A Report of the Sur- geon General, 1972. 2. The Health Consequences of Smoking, 1973. 3. The Health Consequences of Smoking, 1974. 4. The Health Consequences of Smoking, 1975. 5. r he Health Consequences of Smoking, A Reference Edition, Each report since the original “Surgeon General’s Report” has reviewed the scientific literature relevant to the association between xiii smoking and cardiovascular diseases, non-neoplastic bronchopul- monary diseases, and cancer. Smoking as related to the following diseases and conditions has been reviewed periodically in these reports: Allergy (1972) Exercise Performance (1973) Harmful Constituents of Cigarette Smoke (1972) Noncancerous Oral Disease (1969) Overview: The Health Consequences of Smoking ( 1975) Overview: The Health Consequences of Smoking (1976) Peptic Ulcer Disease (1967, 1971, 1972, 1973) Pipe and Cigar Smoking (1973) Pregnancy (1967, 1969, 1971, 1972, 1973) Public Exposure to Air Pollution from Tobacco Smoke (1972, 1975) Tobacco Amblyopia (1971) THE 1977-1978 REPORT This publication, The Health Consequences of Smoking, 1977-1978, contains the most recent data on the health effects of smoking unique to women and on the effects of smoking on overall mortal- ity. Although emphasis is on the most recent data, research from earlier years is included where necessary for clarity. The report was prepared in the following way by the staff of the National Clearinghouse for Smoking and Health, a division of the Bureau of Health Education, Center for Disease Control, Public Health Service: 1. The Technical Information Center of the Clearinghouse con- tinually monitors and collects the scientific literature on the health effects of smoking by means of several established mech- anisms: a. An information science corporation is under contract to extract articles on smoking and health from the scientific litera- ture of the world. b. The National Library of Medicine, through the MEDLARS system, provides a monthly listing of articles on smoking and health. Articles not provided by the information science cor- poration are obtained for review. c. Staff members review current medical literature and iden- tify pertinent articles. 2. Initial drafts for the present report were prepared by the staff of the National Clearinghouse and sent to experts in the content area for review and comment regarding the format, the appro- priateness of the articles selected for discussion, and conclusions. The drafts were then revised by the Clearinghouse to incorporate these comments. The final drafts of the complete report were reviewed by the National Cancer Institute, the National Heart, Lung, and Blood Institute, the National Institute of Environ- mental Health Sciences, the National Institute of Child Health and Human Development, and by additional experts both inside and outside the Public Health Service. ACKNOWLEDGEMENTS The National Clearinghouse for Smoking and Health Director, Dan- iel Horn, Ph.D., was responsible for the preparation of this report. Medical Staff Director was John J. Witte, M.D. The consulting and technical editors were Elvin E. Adams, M.D., and Susan J. Dillon, respectively. The Technical Information Office responsible for the literature collection was Donald R. Shopland. The professional staff has had the assistance and advice of the following experts in the scientific technical fields whose contribu- tions are gratefully acknowledged: AUERBACH, Oscar, M.D.—Senior Medical Investigator, Veterans Administra- tion Hospital, East Orange, New Jersey XV COHEN, Lawrence S., M.D.—Professor of Medicine, Chief of Cardiology, Yale University, School of Medicine, New Haven, Connecticut FITZPATRICK, Mark J., M.D., M.P.H.—Fairhaven, Massachusetts FRAZIER, Todd M.—Assistant Director, Center for Community Health and Medical Care, Harvard Medical School, Boston, Massachusetts KRETCHMER, Norman, M.D., Ph.D.—Director, National Institute of Child Health and Human Development, Bethesda, Maryland KRUMHOLZ, Richard A., M.D.—Medical Director, Institute of Respiratory Diseases, Kettering Medical Center, Kettering, Ohio LEVY, Robert I., M.D.—Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland MARINE, William M., M.D.—Professor and Chairman, Department of Pre- ventive Medicine and Comprehensive Health Care, University of Colorado Medical Center, Denver, Colorado McMILLAN, Gardner C., M.D.—Associate Director for Etiology of Arterio- sclerosis and Hypertension, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland MEYER, Mary B.—Associate Professor, The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland NICHOLS, Ervin E., M.D.—Director, Practice Activities, American College of Obstetrics and Gynecology, Washington, D.C. PAFFENBARGER, Ralph S., Jr., M.D.—Epidemiologist, Resource for Cancer Epidemiology, San Francisco Bay Area, California State Department of Health, Berkeley, California PETERSON, William F., M.D.—Chairman, Department of Obstetrics and Gynecology, Washington Hospital Center, Washington, D.C. PETTY, Thomas L., M.D.—Professor of Medicine and Head, Division of Pul- monary Medicine, University of Colorado Medical Center, Denver, Colorado RALL, David P., M.D., Ph.D.—Director, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina REINKE, William A., Ph.D.—Professor, Department of International Health, The Johns Hopkins University, Baltimore, Maryland RENZETTI, Attilio D., Jr., M.D.—Professor of Medicine and Head, Pulmonary Disease Division, The University of Utah Medical Center, Salt Lake City, Utah SCHUMAN, Leonard M., M.D.—Professor and Head, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota UPTON, Arthur C., M.D.—Director, National Cancer Institute, National Insti- tutes of Health, Bethesda, Maryland WYNDER, Ermest L., M.D.—President, American Health Foundation, New York City, New York xvi Chapter 1 smoking-Related Health Problems Unique to Women Contents Introduction ........eceeecre ernest estes Effects of Smoking on the Outcome of Pregnancy ...------ Smoking and Birth Weight ....-eere eer eerrrrtr Smoking and Perinatal Mortality ...--+-+srrrsrrr Long-Term Effects on Physical and Intellectual Development ....-----serrrrrrrtt Carbon Monoxide and Carboxyhemoglobin Levels in Maternal and Fetal Circulation and the Possible Mechanisms of Smoking Effects on Pregnancy ..---+++-++'> Smoking and Its Effects on Cardiovascular Disease Among Women Taking Oral Contraceptives ...--+-eerrrerrrrtt Effects of Cigarette Smoking on Lactation...-+----++++7°" What Women Know About Smoking and Pregnancy ..----: Summary of Smoking-Related Health Problems Unique to Women ....---eereecrersresssse References ...e eer ee reece terre t eet